An Exceptional Team Approach to Complex Care and the Transition Home

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Published on September 28, 2016

An Exceptional Team Approach to Complex Care and the Transition Home

Jennifer Gaudet Esenwine, MSN, APRN

Jennifer Gaudet-Esenwine, MSN, APRN

Urologic patients admitted to Concord Hospital rely on Jennifer Gaudet-Esenwine to help manage their complex care and ease their transition to care outside the Hospital when they return home.

Jennifer is an advanced practice registered nurse with Concord Hospital Center for Urologic Care. She is assigned to the Hospital, fulltime, quickly responding to any changes in patient condition, following up on critical lab results and assessing whether patients are ready to be discharged. She also ensures clear communication between patients, medical providers, nurses and other healthcare support, such as physical therapists, dietary support and home health nurses.

“For patients who have had surgery, I help manage any issues that may come up post-operatively,” she said. “When they are ready to go home, I help with the transition between care in the Hospital to their continued care while at home.”

Jennifer often is the first advanced care person to respond if a urology patient develops problems while hospitalized. Sometimes the condition is urologic. Sometimes it involves a new condition. When the patient goes home, Jennifer combines urologic recommendations with those from other providers in a discharge plan of care to make sure all aspects of a patient’s condition are included.

Adding Jennifer’s position in the fall of 2015 expanded the Center for Urologic Care’s exceptional team approach and helped improve care. By seeing patients more frequently, she can keep providers better informed so they can deal with issues before they become more serious. The close monitoring also can allow patients to be discharged sooner and reduce the likelihood the patient will have to be readmitted.

“I don’t know of any other urology group that is doing this,” she said. “The team really knows what’s going on with every patient all the time.