title: Advanced Practice Nurse Transitional Care Model Promotes Healing in Wound Care.
abstract: Optimally, transition in health care should be seamless and incorporate a well-thought-out patient-centered discharge plan; yet, many hospitalized patients are unprepared for discharge, thereby compromising patient safety and quality of care. Transition of care should include a broad range of time-limited services designed to ensure health care continuity to avoid poor outcomes among at-risk populations. This case study demonstrates that advanced practice nurses (APNs) are in the perfect position to bridge the existing gap, reduce readmissions, and improve patient health. Transition from hospital to home is stressful under the best of circumstances. Naylor's transition of care model and Meleis's transition theory provides the foundation for APNs to manage patients' wounds across the continuum of care. The patient is educated and guided through the convoluted health care system, resulting in decreased discontinuity and improved outcomes and safety.
  
  
  CONCLUSIONS
  A smooth transition between levels of care requires collaboration and care coordination of medical services and health care providers. The result of this continuity is improved patient outcomes, improved patient satisfaction, and reduced medical errors. APNs as care coordinators have the ability to bridge the existing gap between hospitalization and home while preventing readmission.
authors.forename: Carole
authors.initials: C
authors.lastname: Mackavey
mesh_terms: D057179:Advanced Practice Nursing; D000368:Aged; D006801:Humans; D007871:Leg Ulcer / Q000451:nursing*; D008297:Male; D016294:Models, Nursing; D018802:Patient-Centered Care / Q000458:organization & administration*; D000069341:Transitional Care / Q000458:organization & administration*; D014945:Wound Healing