A Patient-Centered Transitional Care Case Management Program: Taking Case Management to the Streets and Beyond

Derenda Lovelace¹, Diane Hancock, Sabrina S Hughes+3

• ¹Derenda Lovelace, MSN, RN-BS, Cm, is the Geriatrics and Extended Care RN Navigator at the Hunter Holmes McGuire VA Medical Center in Richmond, Virginia. She has been an RN for 37 years and a Case Manager for 22 years for the Federal government in the Department of Defense as well as the Veterans Administration in Medical Management and Case Management. Diane Hancock, MSN, RN, GNP-BC, is a certified geriatrics nurse practitioner serving on the Transitional Care Team and managing a caseload in Geriatric Clinic at the Hunter Holmes McGuire Veterans Administration Medical Center in Richmond, Virginia. She has been a nurse for 32 years specializing in Critical Care Nursing for 24 years prior to becoming an NP. She has also worked in private practice in Internal Medicine and Long-Term Care. Sabrina S. Hughes, MSN, RN, is an RN case manager in the Transitional Care Program at the Hunter Holmes McGuire VA Medical Center in Richmond, Virginia. She has been an RN for 13 years with a focus of educating patients on preventative health measures. She is currently enrolled in a Family Nurse Practitioner program and scheduled to graduate in June 2016. Phyllis R. Wyche, FNP-BC, MSN, RN, works in Geriatrics and Extended Care as the NP for the Inpatient Transitional Care Program at the Hunter Holmes McGuire Veterans Administration Medical Center in Richmond, Virginia. She has been an RN for 34 years and an NP for 17 years with a focus on inpatient medicine and geriatrics. Claire Jenkins, PharmD, BCPS, is the Transitional Care Program Clinical Pharmacy Specialist at the Hunter Holmes McGuire VA Medical Center in Richmond, Virginia. After graduating from the South Carolina College of Pharmacy, she completed her PGY-1 Residency at the McGuire VA Medical Center. Cindy Logan, LCSW, provides psychosocial assessments and assists Veterans in accessing needed community services and Veteran benefits in the Transitional Care Program, Home Based Primary Care and Mobile Medical Unit at the Hunter Holmes McGuire VA Medical Center in Richmond, Virginia. She has been a social worker for 15 years specializing in community mental health specifically crisis work.