Transitional Care in Home Health

[keyairrn]

I have recently taken a role as a Transitional Care Nurse. Basically this role is soft marketing. However, my main task is following current patients and new referrals while they are in the facility and transitioning them home smoother. I am supposed to do medication reconciliation, setup any DME that they may need, communicate with discharge planner and MD about the transition home, etc. I am having trouble with coming up with a model to follow. Also, I'm not a marketer by any means and I would like some advice on that as well. Does anyone else do this transitional care? And if so, do you have a certain model you follow?

[JustMeRN]

I recently took on a transitional care role, but my agencies definition of that role is slightly different. We admit a certain group of high risk patients to home care with close relationships with nurse navigators at physicians office. What you are describing sounds a lot like our nurse liaison role.

I recently completed my BSN and did some papers and projects looking at hospital readmission rates. Care transition programs are considered one of the big factors in reducing hospital readmissions, so I wouldn't call what you are doing soft marketing. There is a ton of research, including some on models of care, if you have access to journals (ebscohost etc). You might find some info in here http://ahhqi.org/images/uploads/AHHQI_Care_Transitions_Tools_Kit_r011314.pdf, and the VNAA website has several areas focused on care transitions.