Health First Case Managers Guide Patients and Families Through Healthcare’s Most Challenging Moments

For families facing unexpected hospitalization, Health First Registered Nurse Stephanie Huezo offers one piece of advice above all else: ask questions. “There are resources available that many people don’t realize exist,” she said. 

BREVARD COUNTY • ROCKLEDGE, FLORIDA – When people think about a hospital stay, they often picture physicians making diagnoses, nurses providing bedside care, and therapists helping patients recover.

But behind nearly every discharge is another member of the healthcare team working quietly to ensure patients don’t just leave the hospital; they leave with the support they need to recover.

For Stephanie Huezo, BSN, RN, CCM, a registered nurse case manager at Health First‘s Viera Hospital, that work begins long before a patient heads home, helping to bridge the gap between them and the resources they need.

“People often think we’re the ones deciding when they leave the hospital,” Huezo said.

“In reality, we’re helping coordinate the safest transition possible and making sure patients have the resources they need to be successful after they leave.”

According to the 2025 Brevard County Community Health Needs Assessment, more than 21.6% report feeling very or extremely stressed on most days.

An additional 44.5% describe their daily stress as moderate. Those numbers reflect the growing challenges many families face, from financial pressures and caregiving responsibilities to transportation barriers and chronic illness.

For patients already coping with hospitalization, those stressors can become overwhelming.

That’s where Health First’s case management team steps in.

“We’re really the bridge between the patient, their family, and the physicians,” Huezo said. “We want everyone involved in the patient’s care to understand the plan and feel supported throughout the process.”

Case managers help patients navigate far more than discharge paperwork.

They connect individuals and families with community resources, coordinate rehabilitation or skilled nursing placements, arrange home healthcare, help initiate Medicaid screenings for uninsured patients, identify transportation services for medical appointments, and connect patients with assistance for food, housing, and utilities when needed.

“A lot of people don’t realize we can help connect them with community services,” Huezo said.

“Sometimes they don’t know transportation is covered through their Medicaid benefits, or that there are organizations that can assist with food or utilities. Being able to connect them with those resources can make a tremendous difference.”

For older adults and families facing difficult diagnoses such as dementia, those conversations often become even more emotional.

Families frequently want to care for loved ones at home, even when the level of care required exceeds what they can safely provide.

“I understand that,” Huezo said. “Families want to do everything they can. But sometimes rehabilitation or specialized memory care is simply the safest option, even if it’s only temporary.”

Rather than simply presenting options, Health First case managers encourage families to tour rehabilitation facilities, ask questions, and become active participants in planning their loved one’s next steps.

“We want them to feel comfortable with the transition,” Huezo explained. “It’s about setting realistic expectations while making sure patients receive the level of care they need.”

Some of the most meaningful work happens during life’s most vulnerable moments.

Huezo says helping families navigate conversations surrounding palliative care, hospice, and end-of-life decisions remains among the most challenging and rewarding aspects of her role.

“Those conversations are never easy,” she said.

“Our goal is to make sure everyone understands the patient’s wishes and knows what services are available. It’s about helping families make informed decisions that honor their loved one’s goals of care.”

Even seemingly small interventions can have a lasting impact.

Huezo recalls helping one visually impaired patient discover that transportation to medical appointments was already included through her Medicaid benefits.

Without reliable transportation, follow-up care often becomes difficult, increasing the risk of returning to the hospital.

Transportation remains a significant barrier to healthcare for many local residents. According to the 2025 Community Health Needs Assessment, 14% of Brevard County residents say transportation has hindered a doctor’s visit in the last year.

“Patients simply don’t know what’s available to them,” she said. “If we can remove one barrier, we’re helping improve their chances of staying healthy.”

Huezo emphasized that successful patient care depends on every member of the healthcare team working together.

“It’s not just case management,” she said. “It’s physicians, nurses, therapists, technicians, patients and families. Everyone has a role. When we communicate well and work together, patients have a much smoother transition.”

By connecting patients with primary care providers, community organizations, and ongoing support services before discharge, Health First’s case managers help reduce unnecessary hospital readmissions while empowering patients to continue their recovery closer to home.

For families facing unexpected hospitalization, Huezo offers one piece of advice above all else: ask questions.

“There are resources available that many people don’t realize exist,” she said.

“Don’t be afraid to tell us what you’re worried about. Whether it’s transportation, insurance, equipment, or finding additional support, we’re here to help.”

While much of healthcare focuses on treating illness, case managers focus on something equally important: helping patients navigate what comes next.

It’s work that rarely makes headlines but touches thousands of lives each year while providing reassurance during uncertain times, connecting families with critical resources, and helping ensure that when patients leave the hospital, they aren’t facing recovery alone.

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