Reference no: EM133342546

Mrs. Harrison, a 75-year-old widow, entered an urban academic medical center through the emergency department after she fell in her garden and broke her hip. Once at the hospital, she admitted she had not been taking the best care of her diabetes, and her chronic obstructive pulmonary disease caused her trouble occasionally, especially with all the time she spent in her garden. After five days as an inpatient at the hospital and a brief stay in inpatient rehabilitation, Mrs. Harrison returned home under the care of a home health agency, with directions to take ten medications-some of them new to her regimen. Mrs. Harrison's goal was to be able to tend her garden again. The care team's goals were to control her diabetes and ensure her recovery after hip surgery. Once home, the situation deteriorated.Mrs. Harrison's community primary care physician had no idea she had been hospitalized or what had happened with her in-hospital care. Mrs. Harrison's two children-never the best of friends-couldn't agree on how to manage her care, and her son, who serves as the primary caregiver, had to return to work even though he had been promised time off to care for his mother. As a result, Mrs. Harrison had no transportation to her follow-up medical appointments. Someone told her there might be a community agency with people who could drive her to the appointments, but Mrs. Harrison didn't know who to contact or how to set this up.Additionally, Mrs. Harrison's home health agency caregivers didn't show up on time, or as expected. When Mrs. Harrison left rehab for home, she had been given a list of medications, but now she wasn't sure what medications to continue or stop taking. She didn't particularly care anyway, since she couldn't afford all of the medications. Mrs. Harrison was especially confused when her medical bills began arriving: she didn't know what her insurance would cover or where to turn for answers. She was having difficulty coping with post-surgery mobility changes and was becoming increasingly depressed because she could not get around as she had before. Mrs. Harrison felt terribly isolated now that she was homebound; worse, she was terrified to go into her beloved garden because she thought she might fall again and have to return to the hospital.

What do you think attributed to this poor experience?

What role should nurses play in improving care transitions?