The shift in focus from individual episodes of illness to a focus on health and wellness, and population health, has created a need for care coordination to address the complex needs of high-risk patients as they transition through the healthcare continuum. A Vermont medical center identified the Clinical Nurse Specialist as having the requisite skills to fill the role of care coordinator. This article describes the development of the Transitional Care Nurse (TCN) program and includes case studies that exemplify how the TCN can intervene to improve care coordination.

Nurse navigators, in a role that originally focused on a single health condition and improving specified services for an individual patient, have expanded to include care management and care coordination. As the role evolves, nurse navigators are demonstrating proficiency and achieving success transforming care delivery to improve population health while improving quality outcomes, patient satisfaction, and decreasing cost. One innovative health system's clinical nurse specialist team partnered with primary care providers, ancillary care teams, home care, skilled nursing facilities, community agencies, and partners in public health and schools. Clinical nurse specialists, now called “transitional care nurses (TCNs),” have created an accountable community of health for their high-risk population. By following patients from one setting to the next, TCNs identified opportunities for improvement, created innovative programs to bridge gaps, improved teamwork, and integrated care, resulting in lower cost, high-quality care. Results included 50% reduction in hospitalization for patients with chronic disease, pre- and post-TCN partnership. Patients with diabetes were supported with access to diabetes coaches, which resulted in a 12% reduction in AIC, while patients completing pulmonary rehabilitation programs experienced reduced readmission rates from 24% to 2.7%.

OBJECTIVE The aim of this study was to understand the experiences of nurses making the role transition from clinical nurse specialists (CNSs) (hospital based) into transitional care nurse (TCN) roles (community based). BACKGROUND The shift from fee-for-service to value-based care has led to the development of transitional care programs. However, little is known about the perceptions of nurses transitioning from a hospital- to a community-based position. Their perceptions can inform training and future recommendations for the TCN role. METHODS Five of 6 eligible TCNs from a community rural hospital in Vermont who transitioned from a CNS role to a TCN role participated in individual, face-to-face interviews using a semistructured interview guide. Data were audio recorded, transcribed verbatim, and analyzed using the constant comparative method. RESULTS Seven major themes were identified: enhanced patient-centered care, collaboration among the other TCNs, transitioning from expert to novice, recommendations for navigating and negotiating systems, discomfort with the role transition, a level of altruism and autonomy, and recommendations for improving the TCN role. Minor themes supported the major themes. CONCLUSIONS Our findings provide implications to improve the transitions of CNSs into a TCN role. Transitional care nurse programs are essential in transitioning individuals from hospital to home. To achieve maximum benefit from TCN programs and ensure their sustainability, nursing leaders must address gaps in both community resources and TCN training.

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Organizations across the country are redesigning care delivery to improve quality and outcomes, enhance the patient experience, reduce costs, and, ultimately, produce better population health. Leaders from the American Organization for Nursing Leadership engaged key stakeholders to discuss the role nursing can play and the toolkit that will be introduced this year to guide nurse leaders in striving for value.