Reshma Nelapudi, RN, did an outstanding job of coordinating a very difficult discharge. This patient had been in the hospital for over three weeks and continued to have high oxygen demands. This was delaying his discharge to go home with his parents to Northern Washington.

Reshma coordinated with a multidisciplinary team and the family, going into intricate details to assure a safe and thorough discharge. Reshma communicated with the patient and his parents to assure everyone was on the same page. She also went the extra steps to set up a Medicare Case Manager and a Home and Community Specialist to assist the patient and his parents to support him at home and help with future needs.

To get this patient home, Reshma set up medical transport to cover the over-eight-hour medical transport ride home. Reshma also set this patient up with a new primary care doctor and pulmonologist, as well as home medical supply needs. Reshma remained caring and supportive of the patient and his family throughout the discharge process and made it possible for the patient to feel he would have the correct care after discharge.