Peninsula Home Care at Nanticoke and Nanticoke Health Services Provide Continuous Care to Patients during Hospital-Home Transition

Published on - August 24, 2016

SEAFORD, DE – When a loved one is admitted to the hospital for congestive heart failure, it’s not something a family takes lightly. They want to make sure their mother, father, sister, or grandfather receives the best medical attention available. But when the individual is discharged from the hospital, a feeling of panic may set in because family members don’t always know what they should do to continue giving their loved one the quality care they need to recover.

To ease that sense of helplessness and anxiety, Peninsula Home Care at Nanticoke is working collectively with Nanticoke Health Services to provide the best quality care to patients from the moment they are admitted to the hospital to the time they are discharged and head back home to continue their recovery.

“When a patient is discharged from the hospital, they transition from being constantly monitored by health care professionals to being on their own or cared for by family or friends,” said ­­­ Robyn Coughenour, Peninsula Home Care at Nanticoke director of clinical operations. “And while care givers are concerned about the patient’s well-being, they may not have the necessary skills required to care for their loved one’s health needs.”

“We are collaborating with all of our providers to address each individual’s plan of care and address what needs should be enhanced upon discharge,” said Jannan McElroy, Director of Case Management, Nanticoke Health Services. “It works well when a liaison, like a home health provider like Peninsula Home Care at Nanticoke, becomes involved early on in the process. This provides more personalization which ultimately builds the trust of the patient and their caregiver.”

For the last ten years, Marcy Burke, RN and case manager, has been that liaison for Peninsula Home Care at Nanticoke.

“When people are sick they don’t always hear what they are being told in the hospital,” said Burke. “That’s why we are here. We help make the transition from hospital to home as smooth as possible. This requires the patient to understand their plan of care upon discharge and have the support, resources and education they need to not only prevent readmission to the hospital but continue their recovery at home and eventually gain their independence to get back to their lives.”

Long Distance Health Care for High Risk Patients

Patients diagnosed with congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD) are known to have the highest hospital readmission rate.  When not managed properly, they are among a handful of chronic illnesses that can lead individuals back to the revolving door of the hospital with little time in between visits.

Peninsula Home Care at Nanticoke’s telehealth system lowers a patient’s readmission risk. The free service provides patients with high-tech medical monitors that track health conditions and alert home care nurses of any issues, recurrences or flare ups.

“Patients at risk for repeat hospital admissions due to chronic conditions often require close home monitoring to prevent any exacerbation of their condition,” said Burke. “These monitors do not replace the home visits our nurses and therapists make. They are an additional tool to prevent readmissions to the hospital, keeping people in the comfort of their home during recovery.”

The monitors provided to patients track and record critical health information such as blood pressure levels, pulse-rate, weight and blood oxygen saturation levels.  For a CHF patient, a change in weight could signal a red flag to the nurse and support can be provided sooner than later which could save the patient a trip back to the ER.  

Facts about CHF

Congestive Heart Failure is the leading cause of hospitalization in people older than 65.  It is a chronic condition in which the heart doesn’t pump blood as well as it should. As a result, the heart cannot pump enough oxygen and nutrients to meet the body’s needs. 

Managing CHF

To keep heart failure from worsening, a patient must make major changes in his life. They may need to eat differently, remember to take medication and keep as active as possible.  Here are some other tips to follow when managing CHF.

  • Keep blood pressure low
  • Monitor your symptoms
  • Maintain fluid balance
  • Limit how much salt (sodium) you eat
  • Monitor your weight
  • Take your medication as prescribed
  • Schedule regular doctor appointments 

About Peninsula Home Care at Nanticoke

Providing care for more than 30 years to more than 39,000 patients on Delmarva, Peninsula Home Care at Nanticoke in Seaford, Delaware ensures that all patients are involved in their plan of care and strives to give them every opportunity to maintain their independence in the home. In 2016, Peninsula Home Care at Nanticoke achieved the highest star rating (5 out of 5) in patient satisfaction survey results.  For more information, visit


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