Abstract
Nursing presence is the foundation of a long-term nurse-patient relationship that improves clinical decision making and ultimately patient outcomes. A home-based, advanced practice nurse-directed program uses presence at the heart of service delivery in an outpatient heart failure program that addresses complex healthcare needs of this patient population. The Community Case Management program has the following goals: (1) to improve access to appropriate cost-effective healthcare, (2) to prevent hospitalizations, and (3) to improve quality of life. An advanced practice cardiac nurse conducts home visits providing skilled nursing assessments, targeted education, emotional support, and advanced care planning to a vulnerable group of heart failure patients. Common nursing interventions are patient and caregiver education, therapeutic presence, supervision of adherence, and advocacy. The Community Case Management program provides a full continuum of care including disease management, case management, and palliative care serving patients and loved ones over the duration of their illness until death. Community Case Management results in fewer emergency room visits, unplanned hospitalizations, cost avoidance, as well as high patient satisfaction and improved quality of life. It is the contention of this author that the success of the program, while resting on expert multidisciplinary care, is also influenced by the spirit of a long-term therapeutic relationship that develops between the nurse, patient, and the patient's loved ones.