Transitional Nursing Care


The transitional care model is designed to prevent health complications and rehospitalization of elderly hospitalized patients with chronic illnesses by providing them with comprehensive discharge planning and in-home follow-up, coordinated by a “transitional care nurse” from master's level who is trained to care for people with chronic illnesses. At the time of hospitalization, the nurse:



  1. perform a comprehensive assessment of the patient's state of health, health behaviors, level of social support and goals.

  2. develop an individualized care plan in accordance with evidence-based guidelines, in collaboration with the patient and her physicians; and

  3. conduct daily patient visits, focused on optimizing patient health upon discharge.



 


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