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Transitional Care emphasizes achieving longer term positive outcomes, by assuring  patients and their family caregivers have the knowledge and skills to recognize and address health care problems as they arise. Transitional care is guided by a clinical point person, who follows patients from hospitals into their homes (or next site of care), and using an evidence-based care coordination approach, provides services designed to streamline plans of care and interrupt patterns of frequent acute hospital or emergency department use and health status decline. The Transitional Care Team collaborates with physicians, nurses, social workers, discharge planners, pharmacists, and other members of the health care team in the implementation of tested protocols with a unique focus on increasing patients' and caregivers' ability to manage their care.

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A significant part of the Transitional Care NP role is to facilitate each patient's and family caregiver's ability to manage his/her care at home. The Nurse Practitioner begins this process at the point of hospital admission, working with each patient and family caregiver to identify their goals. Across the next one- to three-months, in the home, the Nurse Practitioner helps patients develop systems for effectively managing their own care and achieving their goals. The Nurse Practitioner works with the patient and family caregivers to develop an individualized, realistic plan of care that includes strategies to reach positive health outcomes aimed at preventing future acute care events. The primary goal is to help patients and families develop the knowledge needed to identify and address health problems when they first occur. Each plan is customized and tailored to the individual patient and identifies the resources and level of change that patients and their family caregivers are willing to accept and able to execute. At hospital admission and the first home visit, the Nurse Practitioner performs medication reconciliation to assure the correct medications, in the correct doses, are documented in the patient's medical record and present in the home. Additionally, the NP assesses the patient's current system for managing medication and obtaining refills, and suggests changes to medication behavior as needed (e.g., obtaining pill planners, 90 day supply ordering). In addition, the Nurse Practitioner identifies environmental risks, social needs and available supports, and arranges community services as needed.

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The purpose of the evidence-based Transitional Care is not to provide ongoing care to patients, but to optimize patient outcomes throughout and following an acute episode of illness. The major goal of this model is to help the patient and family caregivers develop the knowledge, skills and resources essential to prevent future decline and rehospitalization. At the end of this episode of care, continuity is assured by excellent communication with the primary care providers; and, continuing to follow patients who have made a commitment to their self-management goals. In some cases, the Transitional Care Team will help facilitate access to palliative care or hospice services, assisted living, or chronic case management, based on the individualized needs and preferences of patients and their family caregivers. A transition summary prepared by the Transitional Nurse Practitioner is provided to patients and primary care providers who will assume responsibility for continuing care. The patient's goals, progress in meeting these goals and on-going or unresolved issues with the plan of care are addressed in these summaries.


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