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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
slide7
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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