Healthcare in the United States is complex and complicated. Patients are often left on their own without a roadmap. The needs of the patient may be numerous. Coordinating care at home and negotiating between systems and providers adds to the complexity. A patient with a chronic illness and multiple comorbidities may find their care fragmented or in silos. Limited English proficiency or limited financial assets also contribute to a patient not following up with care. Patients with chronic and complicated medical histories, particularly the elderly, need assistance navigating the healthcare system, specifically transitioning between care settings and adjusting to life back at home with all the necessary resources in place for success. A home care nurse case manager has unique insight into the barriers a patient experiences in the home setting and can anticipate what may have been lacking throughout the discharge planning process. Thorough communication and thoughtful collaboration among healthcare providers are essential to the patient’s plan of care. Poorly coordinated care leads to poor patient outcomes. There is an increasing focus on care coordination and management across settings, as well as patient-centered care. As you learned in Module 3, patient-centered communication and care acknowledge the patient as a partner and driver of their own health care. As a home care nurse case manager, you will quickly learn how patient-centered care fosters care that is well-coordinated and safe and ensures that all the patient's needs, values, and preferences are respected. 

• Faculty: Heather Fitzhugh-Boehm
• ID: Pr-034666