1 / 8

Transitional Care Nursing Jason Marchi , RN, BSN Carolyn Fenn , MS, LSW

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

zagiri
Download Presentation

Transitional Care Nursing Jason Marchi , RN, BSN Carolyn Fenn , MS, LSW

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Transitional Care NursingJason Marchi, RN, BSNCarolyn Fenn, MS, LSW April 23, 2012 Maristhill Nursing & Rehabilitation Center

  2. 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

  3. 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”

  4. 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

  5. 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

  6. 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

  7. 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

More Related