Lieberman Center recently welcomed Nurse Navigator, Maureen Spathies, RN. A native of Chicago, Spathies previously held the position of Discharge Planner at Central DuPage Hospital. She received her Nursing degree from Marquette University, and she has a Master’s.
Spathies manages Lieberman Center’s Transitional Care, which involves the coordination of health care during a movement from one healthcare setting to another or to home. What are her specific duties as a Nurse Navigator? Simply put, she helps make sure that the transition of patients from the hospital to rehabilitation at Lieberman Center goes smoothly. Then, upon their discharge from Lieberman, she helps with their transition to home or another setting.
Her background in Discharge Planning has prepared her well for this position. She has great empathy for the impact a sudden accident or illness can have on patients and families. She is knowledgeable about the indecisiveness and stress that occurs when a debilitating health condition seemingly comes out of nowhere. She continues, “People feel like they have no time to think and there are many options. It is overwhelming and they often vacillate between one plan or another.”
Spathies is at Lieberman to help patients and families during these times. The process will usually start when she gets a referral from a hospital, or a direct call from a family member. She reviews the patient’s clinical data, requests updates, and then determines if Lieberman will be able to meet all the patient’s needs. Then she makes an onsite visit at the hospital to meet with the family and determine their goals—such as whether they want the patient to return home or go into long-term care, for example. She also reviews essential health care requirements such as oxygen and also looks at patient comorbidities, and the details of any Advanced Directives (Do-Not-Resuscitate orders, etc.). All of this may lead to an admission, which Spathies says is not an immediate process, though families often expect that.
“We’ve advanced our Transitional Care Program by adding a Nurse Navigator who will provide an enhanced patient-care experience, with the ultimate goal of improving health outcomes. It was implemented to reduce hospital readmissions and additional health care costs. Like all our Lieberman staff members, our Nurse Navigator cares deeply about how well our rehab patients do once they go home. She carefully monitors them for up to 60 days after discharge, making scheduled visits to their homes to see how patients are doing.”
Executive Director, Lieberman Center
Spathies can then facilitate a patient’s transition from the hospital to Lieberman’s rehab program. About a week or two before a patient is to be discharged, she gets involved by attending the patient’s care conferences with other Lieberman staff, such as the social worker, physical therapist, and nurse manager from the patient’s floor. Then the patient is discharged as planned.
Post-discharge, Transitional Care entails many specific tasks and follow-up duties. The Nurse Navigator accompanies patients (with consent) to their first physician visit after discharge. She helps translate and clarify for patients the often-complicated physician instructions concerning treatment plans and medications. Spathies says she can “act as an avenue of communication, an interpreter of the physician’s instructions, and maybe even slow them down a bit to make things more understandable to patients.” Then she can communicate the physician’s instructions to the caregiver … or the home health care person … or the family. She adds that it is often just about “reminding everyone about care needs and reiterating for them what the care plan is.”
Spathies basically functions as a helpful liaison between care providers and patients at home. Her major goal after discharge is to coordinate with home care providers and make sure the care plan is being followed, that they are aware of medicine interactions, and other tasks. This monitoring of patients lasts for several months. She explains how it works: “We continue to follow up to make sure that the home care plan for the patient is successful. If it is working, plans proceed. If it appears it is not working, we readmit them to Lieberman to prevent a rehospitalization.”
With enhanced patient care and prevention of rehospitalization the goals of Nurse Navigation, it is indeed a vital job in the provision of a fluid continuum of care for those who find themselves in need of rehabilitation. And Lieberman Center is very proud and privileged to offer this value-added service.
Lieberman Center is conveniently located near Old Orchard in Skokie. We are currently accepting patients on an ongoing basis. If you or a loved one are in need of short-term or long-term care, please call 847.929.3320.