Nobody wants to return to the hospital shortly after being discharged. Saint Francis Medical Center’s Continuing Care Clinic aims to help patients take the necessary steps to stay out of the hospital.
“We provide ongoing management for their chronic disease,” says clinical coordinator, Bernadette Huston, MSN, RN, ACNS-BC, ACCNS-AG. “I am the patients’ advocate as they navigate the medical system.
I follow up with patients after a heart attack and with patients who have congestive heart failure. I coordinate follow-up calls for discharged patients and provide information about nutrition, exercise and medication.”
When possible, patients see their primary care physicians shortly after discharge from the hospital. However, if that proves difficult, they can receive follow-up care at the Continuing Care Clinic.
“We act as a point of contact after discharge as they work to keep their disease under control,” says Thomas S. Diemer, MD, internal medicine physician and medical director of the clinic.