Susan Ust is a full time Case Manager for the VNA Health Group. She has been working for the VNA since 2001. The three strongest characteristics to describe Sue are; uses evidence-based practice to achieve positive patient outcomes, educates individuals on prevention of illness, alleviation of pain & suffering, wellness & best possible quality of life. Sue provides excellent care by teaching patients about health and wellness assisting so they can remain save at home and in their communities. She is a very efficient nurse making sure her patients are educated in disease process, medication regime, treatments, home safety, and prevention of falls. As the nurse Case Manager, she is the lead person of the interdisciplinary team and reinforces coordination of care to achieve positive outcomes and prevention of re-hospitalization. Sue is great member of Team C63 always assisting her colleagues and manager. Over the years as her supervisor we have discussed many difficult cases and together designed the best plan possible for the patient. There is one particular case that she took care of from July 2020 to March 2023 (with only 1 re-admission to the hospital) Mr. M, a patient who required a monthly urinary catheter change. In the most recent episode he had a decline in status and it was evident that Hospice was the best option for him. The family, especially the daughter, was not ready and could not face the reality of the father’s condition. With the help of Sue’s patience, encouragement and instruction, the daughter finally agreed to the Hospice transfer. With the help of Sue Ust, the patient is receiving the best options at home for his condition. She always thorough and responsive leaving no room for doubt that the job will get done. Sue is very kind, patient, and never seems frazzled by the challenges of community health nursing.