Utilizing Transition Guide Nurses to Facilitate Patient Transitions and Reduce Readmissions

Course overview

The Transition Guide program represents a true collaboration between the hospital and its health system home care group to support patients discharging from the hospital, specifically those not eligible for (or accepting of) skilled home care or a subacute facility. The Early Screen for Discharge Planning (ESDP) screening tool was employed to identify patients who need support upon discharge and are at higher risk for readmission. Patients most often served by this program have been assessed to be at risk for readmission due to lack of health insurance and access to ongoing primary care, inconsistent management of chronic illness at home, absence of pharmacy coverage or income to pay for medication, homelessness, mental illness and active substance use. Transition guide nurses are embedded within and are considered a central part of the hospital-based care management team. This session provides information to replicate this program at other settings and performance outcome metrics are reviewed.