A Transitional Care Model Using Faith Community Nurses.

Area of Science:

• Nursing
• Healthcare Management
• Public Health

Background:

• Hospitals face pressure to reduce 30-day readmissions due to the Medicare Mandatory Readmission Reduction Program.
• Identifying predictive factors for readmission and effective interventions is crucial for healthcare facilities.

Observation:

• A systematic literature review identified key factors predicting patient readmission.
• Pre- and post-discharge interventions were found to decrease readmission rates.
• Faith Community Nursing (FCN) offers a unique approach to patient care coordination.

Findings:

• A Faith Community Nurse (FCN) Transitional Care Model was developed based on literature review.
• The model outlines specific FCN care strategies implemented before and after hospital discharge.
• These interventions aim to facilitate patient transitions, promote holistic well-being, and reduce readmissions.

Implications:

• This model provides a practical framework for implementing FCN-led transitional care.
• It offers a strategy for hospitals to meet Medicare readmission reduction goals.
• The model supports a patient-centered approach to care, enhancing health outcomes and potentially lowering healthcare costs.