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A reassuring voice. A knowledgeable resource. A helpful reminder. When it comes to navigating the complex world of health care, sometimes these things are all you need to feel connected … and to get connected to the services you need.

Breast care: a needed nudge
Stroke care: sharing experiences
After the hospital: healthy and at home

A needed nudge
Fear of pain, lack of insurance and limited access to transportation are just some of the reasons why many black women skip their yearly mammograms. With more black women than white women in Chicago dying of breast cancer, these missed screenings are a major health concern. For this reason, the No. 1 duty of Shama Shrestha, BSN, RN, a breast health nurse navigator at the Rush Breast Imaging Center, is to call and connect with women who are due for screening and diagnostic mammograms and who need tests such as biopsies. If money is an issue, she refers patients to financial assistance programs. If patients are unable to drive or use public transit, she provides vouchers for free cab fare. And if Shrestha senses fear, she explains how the tests work and emphasizes the importance of early detection. "I stress that the benefits of these tests certainly outweigh the risks," she says.

Sharing experiences
The road to recovery after a stroke often requires rigorous rehabilitation therapy and ongoing follow-up care. The risk of having another, more debilitating, stroke is high, making the recovery process even more stressful. While support groups are helpful, they require travel, which is challenging for stroke survivors who are no longer able to drive and don't want to be dependent on others for transportation. That's just one reason why Rush created the Stroke Buddy Program — to bring mini support groups to stroke survivors in their homes. Comprising the patient, a trained health care student and another stroke survivor, the support group meetings happen over the phone.

These ongoing conversations provide patients with helpful advice from a peer and from someone with health expertise, as well as reminders about upcoming doctors' appointments, ways to recognize stroke warning signs and practical tips for living with disabilities.

"These phone conversations promote independence and awareness," says Shyam Prabhakaran, MD, director of the Comprehensive Stroke Program at Rush. "And this, we hope, will translate into fewer repeat strokes."

Healthy and at home
After being discharged from the hospital, some older adults stop following doctors' orders, risking their health and increasing the likelihood of repeat hospitalization. Although discharge planners give patients tools to recover at home, unexpected problems, such as medication side effects, often complicate matters. To nip problems in the bud, social workers at Rush call older patients who are at high risk for hospital readmission — and their caregivers — soon after they return home.

Social workers review patients' discharge plans and discuss follow-up tests, medication regimens and at-home services such as physical therapy. The social workers determine if everything is going according to plan or if they need to intervene. They often uncover information not shared with doctors, such as a patient discontinuing medications due to unpleasant side effects. Social workers can then inform physicians, enabling better patient care and decreasing the likelihood for hospital readmission. "Our goal is to help patients thrive and return to being as independent as possible," says Madeleine Rooney, a social worker with the Enhanced Discharge Planning Program.

Shyam Prabhakaran, MD, is evaluating ways to improve emergency medical services for stroke patients through telemedicine, a videoconferencing system that brings the expertise of stroke neurologists to other hospitals.

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