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Geriatric patients with chronic illnesses face similar issues. Rebecca Johnson, Ph.D., RN, directs the Center on Aging at the University of Missouri Sinclair School of Nursing.

"Reimbursement of hospital expenses has gone down for older adults, so they're not in the hospital as much," she said.

When they move home, someone needs to teach the patient and family members about how to care for someone suffering multiple diseases. Education and experience make nurses especially suited to teaching older adults how to stay healthy, said Johnson, who is also a professor of gerontological nursing research and public policy.

"One thing we do well is monitor and manage chronic illness," she said.

Nurses are trained to watch for negative reactions to the myriad drug combinations that older patients must take. Furthermore, Johnson said, nurses are adept at looking at a patient's social network to identify a support system of family and friends who will help when the nurse isn't present.

Team players

To help patients find needed support, an increasing number of nurses working with chronically ill patients find themselves part of organized case management teams. These teams smoothly lead the patient through the discharge process. Working together, nurses and social workers not only act as liaisons to the insurance company, but they also educate patients and their families about care at home. They can set up a network of support that includes counseling, nutritional guidance and physical therapy.

Alison Faust, RN, assesses the needs of patients ready for discharge from the University of Colorado Hospital oncology unit. She can devote more attention to setting up resources for her clients, like physical or occupational therapy, because she has two partners in a case management team.

One, a utilization nurse, polices the patient's condition to make sure it meets insurance criteria for hospitalized care. The other, a social worker, organizes the less common but more complicated discharges, such as when a patient is sent to hospice or a nursing home.

The system works well not only for patients, but also for their families, Faust said.

"The families can be so overwhelmed," Faust said. "They don't know who they can talk to and who has all the information." The patients may live longer, but as a result of living with cancer they need more visiting nurses, more equipment and more hospitalization for pain management, she said.

Faust works closely with a team of social workers who visit her discharged patients. She briefs Cheryl Volmert, MSW, and Priscilla Ingebrigtsen, MSW, on the patient's medical condition, so they can anticipate some of the eventual problems a person might face.

"There are a variety of side effects to treatment that can crop up," Volmert said. Many of these issues can be resolved before something truly dangerous happens. "A lot of what we do is preventive. You don't want the patients to be rehospitalized."

For example, if an elderly patient suddenly has mobility issues, the social workers scramble to find in-home care, often working with the insurance company to secure the money. Or they arrange for a physical therapist to find ways to make a home safer for the patient.

Now that patients are living longer, at-home care often is given by spouses, Volmert said.

"We do see many frail elderly who are facing their death at a later stage in life than they might have in the past, and there are some unique challenges," Volmert said. For example, an 85-year-old man may have as his primary caregiver his 80-year-old wife. "There are a lot more supports we need to plug into the home if the family has determined to keep the patients at home," she said.

Volmert said the nurses and doctors appreciate social workers' ability to take on some of the day-to-day responsibilities for patients.