Samantha is a heart failure nurse coordinator who works at the Baptist Advanced Heart Failure clinic and cares for patients with advanced stages of heart failure. These patients usually have multi-organ dysfunction, with at least one end-stage organ disease. Care for these patients is complex and requires frequent clinic visits and medication adjustments, coupled with the involvement of multiple subspecialties.
As a care transitions nurse, Samantha consistently goes above and beyond for the medical care of the patient. She prioritizes the development of relationships with each patient and getting to know them personally. By seeking to understand our patients more holistically, she not only has the skills to coordinate the care of the patient in the heart failure clinic but identifies the individual patient needs in the community that goes beyond routine cardiac care.
The patient is an elderly patient with a history of kidney transplantation, severe end-stage congestive heart failure, and adult-onset blindness. She was referred to the Advanced Heart Failure clinic when her heart disease progressed, and her regular cardiology team could not care for her any longer. This coincided with the recent passing of her husband who was the love of her life and main support system.
During the initial visit and discussion with the patient, Samantha identified multiple gaps in communication between the patient and her providers within two different healthcare systems. She also devoted extra time to connect with her and learn the non-medical aspects of her life with physical and emotional barriers, which likely worsened the progression of her disease. Samantha quickly identified the loss of the patient's husband was a major physical and emotional barrier to appropriate patient care. Like the majority of outpatient clinics, the Advanced Heart Failure clinic relies heavily on written communication to provide medication regimen changes and instructions for patients. Samantha realized that this would not be possible for this patient and had to identify other ways of communicating information. The patient relies on technology-assisted communication for her care, which is not widely used in the outpatient healthcare setting. She has a computer program for the visually impaired that has the ability to read emails out loud to her and create emails back to the provider with questions.
Although this technology is not the standard of care for patients like this one, it helps improve compliance and ensures access to correct medications in a timely fashion. Using this technology, Samantha has not only been able to coordinate her heart failure care but to coordinate care between two different healthcare organizations. This has offered reassurance and comfort to the patient that she is getting great care and there is communication among providers.
With excellent care coordination for the patient, she has been able to manage her care without any hospitalizations despite her diagnosis of advanced heart failure. Samantha has been able to take patient care outside of the acute care setting and reach the patient within their community. The patient is one of many patient examples where Samantha has individualized patient care based on unique needs to have a powerful impact on a patient's life.