A Transitional Care Model Using Faith Community Nurses.
The Medicare mandatory readmission reduction program has hospitals scrambling to reduce 30-day readmissions. A Faith Community Nurse (FCN) Transitional Care Model was developed from systematic literature review of predictive factors of readmission and pre- and postdischarge interventions that decrease readmission. The model presents specific FCN care that occurs pre- and posthospital discharge to support the patient in transitioning from one level of care to another, move toward wholistic health, and avoid unnecessary readmission.
Deborah
D
Ziebarth
Katora P
KP
Campbell
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002835:Christianity; D004509:Education, Nursing, Continuing; D005260:Female; D006801:Humans; D008297:Male; D006278:Medicare / Q000592:standards*; D008875:Middle Aged; D016294:Models, Nursing; D009936:Organizational Innovation; D064698:Parish Nursing / Q000592:standards*; D010351:Patient Discharge / Q000592:standards*; D010359:Patient Readmission / Q000592:standards*; D017410:Practice Guidelines as Topic; D000069341:Transitional Care / Q000592:standards*; D014481:United States