title: Evolving role of the transitional care nurse in a small rural community.
abstract: The shift in focus from individual episodes of illness to a focus on health and wellness, and population health, has created a need for care coordination to address the complex needs of high-risk patients as they transition through the healthcare continuum. A Vermont medical center identified the Clinical Nurse Specialist as having the requisite skills to fill the role of care coordinator. This article describes the development of the Transitional Care Nurse (TCN) program and includes case studies that exemplify how the TCN can intervene to improve care coordination.
authors.affiliation: Jennifer Fels, MS, RN, is a Director Bennington Blueprint, Health Resource Management, Social Services and Clinical Documentation Improvement, United Health Alliance and Southwestern Vermont Medical Center, Bennington, Vermont. Billie Lynn Allard, MS, RN, is an Administrative Director Ambulatory Services and Transitional Care Program, Southwestern Vermont Medical Center, Bennington, Vermont. Karen Coppin, MSN, RN, CEN, is a Transitional Care Nurse, Southwestern Vermont Medical Center, Bennington, Vermont. Karen Hewson, MSN, RN, is a Transitional Care Nurse, Southwestern Vermont Medical Center, Bennington, Vermont. Barbara Richardson, MSN, RN-BC, CCRN, Transitional Care Nurse, Southwestern Vermont Medical Center, Bennington, Vermont.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Fels
authors.forename: Billie Lynn
authors.initials: BL
authors.lastname: Allard
authors.forename: Karen
authors.initials: K
authors.lastname: Coppin
authors.forename: Karen
authors.initials: K
authors.lastname: Hewson
authors.forename: Barbara
authors.initials: B
authors.lastname: Richardson
mesh_terms: D019058:Community Networks / Q000458:organization & administration*; D004509:Education, Nursing, Continuing; D005260:Female; D006801:Humans; D008297:Male; D009720:Nurse Clinicians / Q000193:education*; D024802:Nurse's Role; D017063:Outcome Assessment, Health Care; D019035:Rural Health Services / Q000458:organization & administration; D012424:Rural Population; D000069341:Transitional Care / Q000458:organization & administration*; D014707:Vermont