Juliana Evans, RN, BSN, CCM

Being discharged from the hospital to continue recovery at home can feel overwhelming for patients as they navigate prescription medications, follow-up appointments and other care instructions. Nurse case managers like Juliana Evans from Health New England’s Pathway to Home Program help guide their care journey, making the transition less daunting and ensuring there are no gaps in their care. Baystate Health and Health New England work as one integrated system combining clinical care with health coverage, so the people who deliver your care and the team behind your health plan are working toward the same goal: keeping you healthy.

After Juliana is notified that a Health New England plan patient has been discharged to home, she follows up with a phone call to check on how they are doing, answer questions about their care, and help them access resources.

“I make sure they have everything they need at home to help their recovery go smoothly,” Juliana says. That might mean checking that they are taking prescriptions correctly, are making necessary appointments, and fully understand their condition and treatment plan moving forward.

Juliana talks to patients to learn more about their support system at home and other factors that might impact their healing. Do they have transportation to doctor’s appointments? Can they afford their medications? Are there housing, food insecurity, or other issues that might impede their recovery? Do they need help understanding the details of their Health New England medical plan coverage?

“I’m a little like the life ring you throw people in rough waters that they can grab on to,” she says. “I help relieve pressure and anxiety during a challenging time. And I help them navigate the healthcare system, showing them how to access needed services.”

Juliana checks in regularly with patients over the first 30 days after discharge, providing consistent involvement that can mean the difference between a successful recovery and a readmission to the hospital. Some patients who need ongoing support and connection continue beyond that.

Juliana’s legacy of caring in our community began decades ago when the lifelong Springfield resident started her career in bedside nursing at Baystate Medical Center. Juliana understands her patients’ hopes, fears and concerns as they navigate their health journey – and they appreciate the extra support and the listening ear.

“Just recently, I received a call from a woman whose husband I had cared for. She said she’d called because she missed hearing the sound of my voice,” Juliana says. “In this work, you build relationships. Sometimes you don’t realize how deep they are until those moments when someone comes back to say thank you. I care for these patients and families with my whole heart and soul.”