title: Transitional coordinator nurses focus on at-risk patients with chronic diseases.
abstract: Tucson Medical Center keeps its readmission rates low by having transitional coordinators work closely for patients with chronic disease who are at risk for readmissions. An analysis of readmitted patients determined that many who were rehospitalized were elderly with chronic diseases. The transitional coordinators are three experienced nurses with knowledge of chronic disease who work closely with the care team and follow patients for up to 30 days after discharge. The hospital arranges for post-acute providers to come to the hospital to see the patients referred to them for services.
mesh_terms: D019090:Case Management; D002908:Chronic Disease; D003266:Continuity of Patient Care; D006801:Humans; D024802:Nurse's Role; D040242:Risk Reduction Behavior