Collaboration is critical to managing patients beyond the four walls of the hospital. In order to facilitate this, Memorial Healthcare System has enlisted Marlene Russell, a nurse navigator who follows patients as they transition to post-acute care.
‘It’s my role to collaborate and assist when our patients need placement in group homes, skilled nursing, assisted living, or long-term care facilities to improve their outcomes and prevent readmission back to the hospital,” said Russell. “Sometimes, I work with patients that have been debilitated by poor health, but the root cause is often based on multiple social determinants of health, and within a few weeks of addressing the socio-economic issues and being safely admitted to the next level of care, patients are transformed and feel good again because they have the hand-up they needed from Memorial.”
Russell monitors patients routinely while at the facility to ensure their needs are met. A nurse for nearly 40 years, she says this is the most satisfying time in her career. “Memorial is dedicated to its community and I’m proud to be part of a program that has such life-saving impact.”
