Do collaborative case management models decrease hospital readmission rates among high-risk patients?

Marisa A Bisiani¹, Corinne Y Jurgens

• ¹Marisa A. Bisiani, DNP, RN, ANP-BC, has been in the field nursing for more than 20 years. As a young nurse who began her career as a nurse's aide, she pursued education as a licensed practical nurse and then an associate prepared registered nurse to obtaining a bachelor of science. She received her master of science from Stony Brook, leading her to become a licensed ANCC Board Certified Adult Nurse Practitioner. She recently graduated from Stony Brook Universities Doctorate of Nursing Practice (DNP) program. She works as a nurse executive and she has directed many departments such as care management, allied health professionals, employee health services, and hemodialysis. Her specialty is inclusive of focusing on care transitions, as we move one patient to each level of care. She is exceptionally interested in the work of preventable readmissions and population health. Corrine Y. Jurgens, PhD, RN, ANP-BC, FAHA, is a nurse scientist. Her program of research focuses on patients with heart failure and self-care. In particular, she studies symptom perception, recognition, and response in this population. Her prior work indicates patients lack a context for determining whether their symptoms are heart-related or associated with less threatening illnesses. She conducted a randomized trial testing an intervention based on my prior studies and theory that provides patients with a way to monitor and interpret their symptoms in a meaningful way. Other interests include investigating a phenotype for mild cognitive impairment in patients with heart failure, exploring self-care interventions for frail elders, implementing guidelines for heart failure management in skilled nursing facilities, and examining factors related to symptom blunting in this population.