Evaluation of a Transitional Care Management Tool Using the Logic Model

Jessica S Garner¹, Marisa L Wilson

• ¹Jessica S. Garner, DNP, FNP, is an assistant professor of nursing at the University of Mobile. She has served as part-time faculty for the Capella University School of Nursing and Troy University School of Nursing. She worked as a nurse practitioner in the inpatient setting in the pulmonary and critical care specialty after graduating with her Master of Science in Nursing degree from the University of Alabama at Birmingham in 2014. This position afforded her the opportunity to gain perspective on why patients are admitted to the hospital and why they return. She began her Doctor of Nursing Practice degree through the University of Alabama at Birmingham in 2016 with the intention of focusing on readmissions and the transitional care window, and this article is the culmination of her work during completion of that degree. During her inpatient work, she participated on subcommittees to initiate smoking cessation in the inpatient setting and reduce 30-day readmissions associated with chronic obstructive pulmonary disorder. Marisa L. Wilson, DNSc, MHSc, RN-BC, CPHIMS, FAAN, is an associate professor and specialty track coordinator for the MSN Nursing Informatics program at the University of Alabama at Birmingham School of Nursing and core faculty member in the Doctor of Nursing Practice program teaching informatics for quality, safety, and the transformation of care. Dr. Wilson is also an associate faculty member for the Informatics Institute of the University of Alabama at Birmingham School of Medicine. In 2006, she transitioned her career to full-time academia after 30 years of clinical care, public health, and operational informatics management work. Dr. Wilson received her master's degree from the Johns Hopkins University Bloomberg School of Public Health and her doctorate degree from the Johns Hopkins University School of Nursing. Dr. Wilson spent more than two decades in epidemiological, clinical, and operational informatics work in public health, acute care, and post-acute care settings. She was a 2012 American Association of Colleges of Nursing Leadership for Academic Nursing fellow. She was the Director of Master's Programs, taught in the MS informatics and DNP programs, and mentored graduate students at both the University of Maryland School of Nursing and the Johns Hopkins University School of Nursing. Dr. Wilson is actively involved in MedBiquitous, AMIA, and HIMSS through her work with informatics continuing education programs and mentorship of new informaticians.