By Susan B. Hassmiller, PhD, RN, FAAN, senior adviser for nursing at the Robert Wood Johnson Foundation. This post is also being published at the Robert Wood Johnson Foundation Human Capital blog.

When I heard that the Supreme Court had upheld the Affordable Care Act, I immediately thought of my father. He suffered mightily at the end of his life. Plagued with multiple chronic illnesses, he spent his last year in and out of hospitals. He received good hospital care, but his health deteriorated every time he left the hospital.

He simply couldn’t keep track of a growing list of prescriptions, tests, and doctor visits. He accidentally skipped antibiotics, which led to infections, which landed him back in the hospital. He accidentally skipped blood tests, which landed him back in the hospital. It seemed that every time he came home, he’d land back in the hospital. I lived thousands of miles away and couldn’t be the advocate that he needed.

What he needed was transitional care—he needed a nurse to meet with him during a hospitalization to devise a plan for managing chronic illnesses and then follow him into his home setting. He needed a nurse to identify reasons for his instability, design a care plan that addressed them, and coordinate various care providers and services. He needed a nurse to check up on […]