As a manager for many years in Stanford’s Aging Adult Services program, Nancy Dudley had far too many patients who were at risk of falling through the cracks in a health care system ill prepared to deal with them. Typically, these patients were older adults living with comorbid conditions, including chronic illnesses once considered fatal.
“I’d be called in when they were being readmitted to the emergency room (ER). A lot of them had received specialty care and then lost contact with their primary care physician or even specialty physician [after discharge],” she says. “There were a lot of gaps in coordinating their care.”
A nurse with master’s degrees in nursing administration and gerontology, Dudley knew her patients’ unmet needs went beyond specific diagnoses to what were often stubborn symptoms that drove them to the ER, mental health challenges and “big picture” questions about how they wanted to live and die. She began to believe that the system needed to adapt if it was to help her patients achieve a quality of life that would justify the medical miracles prolonging their lives.