title: Implementation of Transition in Care and Relationship Based Care to Reduce Preventable Rehospitalizations.
abstract: Home healthcare agencies are accountable for preventing rehospitalization, yet many struggle to make progress with this metric. The purpose of this article is to share how our organization turned to two frameworks, Transitions in Care and Relationship-Based Care, to prevent unnecessary rehospitalizations. Appreciative inquiry, motivational interviewing, and action plans are used by our Transitional Care Nurses to engage and motivate patients to manage chronic diseases and achieve desirable health outcomes. Implementation of a Transitional Care Program has led our organization to improve the health of our patients and to decrease rehospitalization rates.
authors.affiliation: Susan Burt, MSN, RN-BC, is a Senior Educator, Center for Learning, Virtua, Mount Laurel, New Jersey. Donna Berry, MSN, RN, is a Team Manager, Virtua Home Care, Mount Laurel, New Jersey. Patricia Quackenbush, MBA, RN-BC, is a Director of Quality Management, Virtua Home Care, Mount Laurel, New Jersey.
authors.forename: Susan
authors.initials: S
authors.lastname: Burt
authors.forename: Donna
authors.initials: D
authors.lastname: Berry
authors.forename: Patricia
authors.initials: P
authors.lastname: Quackenbush
mesh_terms: D002908:Chronic Disease; D019468:Disease Management; D006699:Home Care Services / Q000458:organization & administration*; D006801:Humans; D062405:Motivational Interviewing; D009515:New Jersey; D010359:Patient Readmission / Q000706:statistics & numerical data*; D000069341:Transitional Care / Q000458:organization & administration*