Nursing

3 Ways to build a strong transitional care program

Nurse Leader Insider, November 10, 2016

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The American Nurses Credentialing Center last month awarded the 2016 National Magnet Nurse of the Year Award in Structural Empowerment to Barbara Richardson, MS, RN-BC, CCRN, clinical nurse specialist in transitional care nursing at Southwestern Vermont Medical Center in Bennington.

She earned the distinction for her transitional care nursing work.

The medical center serves a rural region in portions of three states, and began actively using transitional care nursing about three years ago. Since then, there has been a 69% decrease in hospital admissions and 29% drop in emergency department visits among patients enrolled in the program.

The patient cohort is traditionally hospitalized patients connected with primary care practices, Richardson says. "However, it can also be patients or people who have not been hospitalized but who the primary care providers feel are at risk for hospitalization or at risk for failing their medical regimen."

The program, based on Mary Naylor's Transitional Care Model, was launched and led by Richardson and has grown in size from one clinical nurse specialist—Richardson—to one part-time and three full-time clinical nurse specialists as well as a social worker.

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