Nurse Practitioner Transitions Patients from Hospital to Home
“There is nothing more rewarding than helping someone get the care they need when they are at their most vulnerable.”
Suzana Cane learned the value of caring for others when she was just 17. She helped her mother with her uncle near the end of his life. “It gave me the idea that I wanted to be a nurse,” she said, “and be able to help patients and their families through difficult times.”
That experience launched Suzana on an educational journey that went well beyond her Registered Nursing (RN) studies. She earned her Advanced Practice Nurse (APN) credentials. “I wanted to be able to do more to help,” she explained. “Now I am able to treat the whole patient, make medical diagnoses and prescribe medications as needed.”
Suzana brings deep and broad experience to Vanguard. She has worked in a variety of settings, from hospitals to subacute rehabilitation facilities to long-term care. In her role as a transitional care nurse, Suzana visits recently hospitalized patients at home to help in their recovery and to prevent readmission.
The transitional care program starts with a visit to the patient in the hospital. That’s where Suzana introduces herself and explains the program. This is followed by the home visit, which involves a physical exam and time spent with the patient going over medications and follow-up instructions. During the visit, she may make follow-up appointments for specialists, check in with home care agencies, and advise on nutrition and exercise.
She especially enjoys that she can do all of that in a home environment. “In the hospital, it’s easy to become overwhelmed,” she noted. “When patients are home, they are less anxious and more comfortable. It’s an easier time to teach a patient and family members how to use devices, medications, etc. Importantly, I take the time to listen and address their concerns and make sure they are getting the correct care.”
When she’s not working, Suzana enjoys listening to music and watching movies with her two kids. Family is important to her, and she spends as much time as she can with her 93-year-old father.