Chestertown Nurse Assumes New Role in Changing Health Care Landscape

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Angela Pritzlaff, Transitional Nurse Navigator

Over more than two decades serving health care needs in Kent County, Angela Pritzlaff, RN worked in various units at UM Shore Medical Center at Chestertown and also for UM Chester River Home Care. Last August, she joined the new Care Transitions Program at UM Shore Regional Health (UM SRH) as one of four transitional nurse navigators who are working with patients in the health care network’s three hospitals.

UM SRH launched the Care Transitions Program in 2017 to help reduce the number of people with avoidable or unplanned readmissions to the hospital within 30 days of discharge. People with COPD, as well as people with congestive heart failure and pneumonia, are at high risk of readmission, so the new program has focused primarily on “high risk” patients with those diagnoses. When these patients arrive for emergency care or are admitted to the hospital, a transitional nurse navigator (TNN) tracks their care and works closely with their primary care provider and other specialists — and also with family members or other loved ones — to help make sure they will have everything they need when they are discharged.

As a TNN, Pritzlaff helps patients and their caregivers plan to manage their health once outside the walls of the hospital. As she explains, “I gather the information I need to anticipate the full range of issues that might land a patient back in the hospital —problems with medications, psychological issues, his or her main health condition and other health concerns, physical limitations, health literacy, family support, prior hospitalizations and the possible need for a palliative care evaluation. Every patient is unique and their family and life circumstances vary widely, so the obstacles or challenges they might encounter in returning to their home environment differ from one patient to another.”

Depending on a patient’s particular needs, Pritzlaff may schedule follow-up appointments with primary care doctors and specialists, and assist with transportation arrangements if needed. She also is likely to spend some time educating the patient and/or family members about the patient’s health condition and what to do if problems arise after discharge, as well as helping them obtain, understand and manage their medications. “In many cases, a patient’s prescriptions will change during the hospital stay and it’s really important to make sure that the right medicines are taken once he or she gets home,” she says.

Pritzlaff follows up with phone calls to her patients and in some cases, home visits. In the case of patients who are discharged to a skilled nursing, rehab or other residential care facility, she connects with staff there to make sure that the correct medications as well as needed equipment and supplies are available promptly, that meals provided meet patients’ dietary needs, and that timely transportation to and from doctors’ appointments will be arranged.

“It’s really gratifying work,” says Pritzlaff. “Often I am assisting patients and families I have encountered in my previous nursing positions, so there is a sense of familiarity and a true continuum of care that I think people in a small community value.”

According to Nancy Bedell, MBA, RN, regional director of care coordination for UM SRH, the Transitional Nurse Navigator Program is a key population health initiative that supports the organization’s mission of Creating Healthier Communities Together. “The goal here is to help people be well and to take care of themselves and their families,” Bedell says.

As part of the University of Maryland Medical System (UMMS), University of Maryland Shore Regional Health is the principal provider of comprehensive health care services for more than 170,000 residents of Caroline, Dorchester, Kent, Queen Anne’s and Talbot counties on Maryland’s Eastern Shore. UM Shore Regional Health’s team of more than 2,500 employees, medical staff, board members and volunteers works with various community partners to fulfill the organization’s mission of Creating Healthier Communities Together.

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