Individuals living with chronic diseases or conditions need regular, coordinated healthcare even more than the average person does. Yet, low-income or indigent people who live with chronic illness often struggle to maintain their health without a support system. They frequently go without vital medications or periodic doctor visits, relying instead on a hospital emergency room for their healthcare needs.

Baptist Health South Florida physicians observed this trend at Homestead Hospital. Patients treated for chronic conditions such as heart failure and diabetes, then discharged, often returned to the ER or were readmitted to the hospital due to lack of proper follow-up care and failure to comply with doctors’ orders.

Baptist Health saw an opportunity to interrupt this cycle of hospital admission-discharge-readmission. With funding from a Health Foundation of South Florida grant, the Baptist Health Follow-Up Care center opened in Homestead in April 2012. The center provides a temporary “medical home” for patients and assists them in arranging ongoing care.

With oversight from a Baptist Health physician, the Follow-Up Care center is staffed by an advanced registered nurse practitioner with support from a nursing team and an on-staff social worker. These professionals provide transitional healthcare and a continuum of services to needy patients, including:

  • Medication management, with emphasis on sourcing affordable prescriptions;
  • Help with establishing a primary care physician relationship;
  • Connections to social service agencies;
  • Referrals to dental and vision clinics;
  • and Referrals to free or low-cost medical clinics for ongoing care.

This Nurse Practitioner management model is the first of its kind in Florida. Florida International University’s College of Nursing and Health Sciences has collaborated with Baptist Health Follow-up Care to give undergraduate and graduate nursing students experience with the new transitional care model as well as a location to complete their clinicals.

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