Liminal Health Foundation was established by a group of hospital nurse case managers and discharge planners. These case managers and discharge planning nurses are entrusted to assess, evaluate, and prepare patients discharging from the hospital. They percolated in the stew of hospital pressures: inundated by patient load, pressured by hospital throughput, tiptoed to insurance’s dogma of medical necessity, and besieged by hospital finance’s length-of-stay, geometric length-of-stay, and reimbursement. To these dedicated nurses and social workers, the task would have been easier by simply passing the obligation to the next team in the healthcare spectrum; the home health nurses, social workers, physical therapist, in the community. Unfortunately, it became a revolving door of hospital readmissions, medical complications, and to some, death and despair.

These hospital nurses and discharges planners have seen it all: the 68 years old female who lives alone in her rundown family home making difficulty choices between her medications and tax payment, the 32 years old obese male discharged from the hospital, sent home by ambulance, barely able to ambulate alone in his apartment without food, and unable to pick-up his discharge medication, and the 57 years old male, paralyzed from waist down, with stage three sacral decubitus, suprapubic catheter, and contractures, declining to go to the nursing home because it will reduce his monthly government pension to $30/month.

These patients are helpless and needed support and guidance to lead them towards resources available to improve their situation. Unfortunately, and most often, these patients are simply attended and directed to bureaucracies and waiting list. And we know what happens next. These patients fall off the cracks and forgotten amidst the next complex case in the sea of healthcare tragedies and misfortunes. So, where can they turn to? Where do they go? They are resigned, alone, and left to ponder on their limited resources to meet their needs.

After an acute or life changing health situation, patients are referred to nurses and social workers for follow-up and/or continued health support. These healthcare workers assess patient needs and explores resources available to them. At times, they walk with patients into their dirty homes, depleted with food resources, no medications, no help, in smoldering heat or freezing cold. Some homes are infested, no beds, with laundry and garbage scattered through out. This is not conducive to recovery. Fortunately, our healthcare heroes roll their sleeves to help these patients and at times open their pocketbooks to assists with their needs. But like all of us, they have limited resources. This is where Liminal Health Foundation (LHF). LHF provides support and financial assistance when funds and resources are deficient.