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Transitional Care Nursing Jason Marchi , RN, BSN Carolyn Fenn , MS, LSW. April 23, 2012. Maristhill Nursing & Rehabilitation Center. Role of Transitional Care Nurse. Liaison between referring hospitals Interdisciplinary Coordinator Case manager and patient/family advocate

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Transitional care nursing jason marchi rn bsn carolyn fenn ms lsw

Transitional Care NursingJason Marchi, RN, BSNCarolyn Fenn, MS, LSW

April 23, 2012

Maristhill Nursing & Rehabilitation Center


Role of transitional care nurse
Role of Transitional Care Nurse

  • Liaison between referring hospitals

  • Interdisciplinary Coordinator

  • Case manager and patient/family advocate

  • Patient/family educator

  • Quality improvement initiator

  • Contact for community clinicians


Coordinating with hospitals
Coordinating with Hospitals

  • Careful review of discharge summaries prior to patient arrival

  • Follow up with hospital staff for questions/concerns

  • Frank discussion of hospital clinicians’ concerns or “gut feeling” about a given patient’s needs

  • Communication is key to effective “warm hand-off”


Coordinating with community clinicians
Coordinating with Community Clinicians

  • Involvement of home services prior to discharge

  • Collaboration with PCP’s for ease of transition and facilitation of new needs

  • Continued communication with home services

  • Follow up within one week with patient/family for needs assessment


Managing recidivism
Managing Recidivism

  • Implementation of Interact QI tool

  • Weekly group meetings with Administrator, DON, and allied disciplines for needs assessment, case studies, and “lessons learned”

  • Communication with covering physicians as to Maristhill’s treatment capabilities

  • Discussions with patients and families about the principles and benefits of advanced directives


  • BASELINE READMISSION RATE (2010) = 25%

  • Developed and implemented tracking system

  • PHASE II READMISSION RATE (2011) = 19%

  • Education, introductory phases of INTERACT tools

  • Beginning implementation of in-depth QA

  • Hired Care Transitions Nurse, August, 2011

  • PHASE III GOAL READMISSION RATE (2012) = 10%

  • Reduce readmissions of long-term residents by 50%

  • Increase use of palliative care/pastoral staff

  • Implement formal protocol for clinical education/advance care planning for all patients


Surprises opportunities
Surprises & opportunities

  • Importance of “person-to-person” contact

  • Patient/family lack of knowledge about their medical condition, prognosis

  • Variability in recidivism rates among hospitals

  • Staff “culture change” around treating in place: the role of confidence, skills, empowerment in successful outcomes


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