Transitional Care

Aging

Figure: http://www.bvcog.org/wp-content/uploads/2010/11/pic-agency-on-aging.jpg

Minnesota State University Moorhead RN-BSN student in Nursing 420: Gerontological Nursing to Promote Successful Aging will doing a project where they analyze the transitional care process this spring.

When illness occurs, many individuals find themselves transitioning from one healthcare environment to another. Because of the increasing number of chronic diseases in the elderly, that process can become very complicated. Medication, functional, and physiological changes occur during hospitalization and often the impact of those changes isn’t fully recognized. As a result the transition to another setting often results, unintentionally of course, in exacerbations, treatment failures and eventually hospital readmission.

Beginning October 1, 2012, the Affordable Care act added a provision which established the Hospital Readmissions Reduction Program. Payments are now reduced to hospitals with excess readmissions. http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html Money talks and an emphasis on improving the transitional care process is becoming the norm. The “Affordable Care Act includes $500 million to fund pilot projects on transitional care services for “high-risk” Medicare beneficiaries (such as those with multiple chronic conditions and hospital readmissions) at certain hospitals and community organizations over a 5-year period.” It’s a pilot project, but if cost savings are demonstrated after five years it will continue. http://thefutureofnursing.org/resource/detail/transitional-care-model This seems like a win, win for all. The patients and families experience a smooth transition, improved safety and wellbeing and the cost and risk of recurrent hospital admissions are reduced. Once again, nurses can play a pivotal role in this process!

Victoria Teske RN, MS, GNP-BC
Assistant Professor
School of Nursing and Health Care Leadership
213 B Lommen Hall
1104 7th Avenue South
Moorhead, MN 56563

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