complex care aligned with her passion for addressing gaps in patient care and was eager to get involved. The program’s daily operations include running reports to identify eligible patients, providing immediate assistance with medications and transportation, and ongoing case management to ensure patients stay on track with their care. As Eleby puts it, the team acts as a crucial “middleman,” bridging gaps between hospital care and outpatient follow-ups, ensuring nothing falls through the cracks. Eleby’s role involves meeting patients in emergency situations, conducting detailed assessments, and connecting them with the necessary resources. She emphasizes the importance of patient involvement: “It may look like something small at the beginning, but the goal is to take the patient and work on the goals that they have, but also educate them on their health care.” This holistic approach aims to empower patients to manage their health more effectively and ultimately achieve better outcomes. Her dedication to her role is evident in her deep commitment to patient care and her proactive approach to addressing both medical and social needs. Her journey from recognizing gaps in discharge planning to Regional One Health underscores her passion and the profound impact of her work. Reflecting on the broader implications of this work, the complex care program, and this team, Susan said ONE Health can have a profound impact: “If you can improve the health of the individuals, you can improve the health of the community.” 20 2024 Gratitude Report
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