Evolving Role of the Transitional Care Nurse in a Small Rural Community

Abstract

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.

Reducing Preventable Hospitalizations With Two Models of Transitional Care

“…A further description of the origin of the program and case studies of patients enrolled in the program was provided by Fels et al. ().…”

“…Patients were discharged when goals for follow-up and disease selfmanagement were met and the CNS was confident that they would follow through with the plan created. A further description of the origin of the program and case studies of patients enrolled in the program was provided by Fels et al (2015).…”

Hospital to Home: Supporting the Transition From Hospital to Home for Older Adults

“…Integrating healthcare professionals along the continuum of care for older adults, such as discharge planning nurses, acute care nurse case managers, nurse practitioners, or home care nurses, could potentially improve communication between health services and advocate for the health needs of older adults and their unpaid caregivers as they transition between health services ( Allen et al, 2014 ; Thoma & Waite, 2018 ; Weeks et al, 2016 ). Healthcare professionals like nurse practitioners, discharge planning nurses, and home care nurses have valuable expertise and knowledge of health systems and understanding of the challenges older adults and their unpaid caregivers face once they transition home ( Fels et al., 2015 ; Rhudy et al., 2009 ; Slatyer et al, 2019 ; Thoma & Waite, 2018 ).…”

Implementing Enhanced Primary Care Registered Nurse Reimbursement in Rural Health Clinics: A Policy Analysis

“…Transitional Care Management (TCM) is intended to prevent readmissions, missed care opportunities, or gaps in care any time a patient moves between care settings (usually inpatient or skilled care) and the community (RHI, 2018b). Nurse-led care transitions decrease readmissions and improve patient outcomes (Fels et al., 2015; Miller, 2017). TCM is another service that EPC-RNs are equipped to lead and manage in RHCs.…”