Developing a rural transitional care community case management program using clinical nurse specialists.

Area of Science:

• Nursing
• Quality Improvement
• Healthcare Management

Background:

• Aging populations increase the prevalence of chronic diseases, necessitating effective management programs.
• Care transitions are vulnerable periods leading to preventable readmissions, especially for underserved populations.

Purpose of the Study:

• To develop and implement a community nursing case management program to reduce hospital and emergency department readmissions.
• To utilize telephonic case management and onsite assessments by a clinical nurse specialist (CNS) with prescriptive authority.

Main Methods:

• A comprehensive SWOT analysis informed the development of a cost-avoidance model.
• The program focused on uninsured and underinsured patients to prevent readmissions.

Main Results:

• The CNS implemented diverse interventions, leading to a significant reduction in 30-day readmissions for 13 patients over two years.
• A notable decrease in readmissions was observed compared to the pre-program period.

Conclusions:

• Advanced practice nurses, specifically CNSs, are effective in transitional care, preventing readmissions and achieving cost avoidance.
• The program's success highlights the value of CNS expertise in coordinating community resources and managing care transitions.