UM Shore Regional Health is piloting a transitional care program for patients who are high risk for readmission and have congestive heart failure as a diagnosis. A transitional nurse navigator (TNN) is now being assigned to all high-risk CHF patients, at UM SMC at Dorchester and at UM SMC at Chestertown.
The objectives of the transitional care program are to:
• Decrease “avoidable” and “unplanned” readmissions
• Improve effectiveness and efficiency of managing patients with high risk for readmission within 30 days of discharge
• Help patients and families navigate their care on the Shore to ensure a safe and appropriate transition back to home and the community
At UM Shore Medical Center at Dorchester, the new TNN positions are filled by Lori Geisler, MSN, RN and Iris Giraudo, BSN, RN; at UM Shore Medical Center at Chestertown, the TNN is Angela Pritzlaff, RN. Their duties include:
• Coordinating appointments, specifically follow up PCP and specialist appointments after hospital/Emergency Room discharges
• Hand offs to medical staff offices and skilled nursing facilities after discharges
• Following up with patients by telephone and sometimes at the home up to 30 days after discharge
• Patient and family education to improve health literacy
• Completing medication reconciliation for the patient
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