Carmen is a nurse practitioner in the Healthy Lives program, focused on the care of patients with high-risk diagnoses that can lead to frequent hospital readmissions and decreased quality of life. Patients are followed from their inpatient event, prepared for a safe transition from hospital to home or nursing facility, and seen as outpatients to help manage symptoms, become educated in their disease process and treatment, and prevent readmission and ED visits.
Carmen has developed expertise and rapport in the treatment of the COPD cohort of the Healthy Lives population. These patients often have several comorbidities, poor medication compliance, and health literacy. She was instrumental in initiating the In-Home COPD Program. Patients meeting the criteria are seen at the bedside by the NP and Respiratory Therapist (RT) and offered enrollment into the program.
Enrolled patients are seen 3 to 5 days post-discharge in their homes by the RT. The RT communicates with the NP after each visit and the care plan is adjusted as needed. Based on the collaboration with the RT, Carmen has been able to order home equipment and supplies that can help the COPD patients better manage their symptoms. The patients report daily via the Vivify device, a telemedicine device that can record the patients' weight and vital signs. Vivify allows for the patient to call in, request a callback, or video chat with the care team.
Carmen leads the interdisciplinary care team in assuring patients receive optimal care. Under her leadership, 30-day readmissions for COPD patients have declined from 24% in 2018 to 10% in 2019. Carmen develops sustaining, trusting, caring relationships with the In-Home Program patients, truly creating a healing environment for this challenging patient group.