Our Nursing Profession at a Crossroads: Time to Chart a Course for the Future.

Area of Science:

• Healthcare Management
• Nursing Practice
• Population Health

Background:

• Nurse navigators' roles have evolved from single-condition focus to comprehensive care management and coordination.
• The evolving role demonstrates success in transforming care delivery for improved population health outcomes.

Purpose of the Study:

• To evaluate the impact of an innovative transitional care model implemented by clinical nurse specialists.
• To assess the effectiveness of transitional care nurses (TCNs) in managing high-risk patient populations.

Main Methods:

• A clinical nurse specialist team, rebranded as transitional care nurses (TCNs), partnered with diverse healthcare providers and community agencies.
• TCNs followed patients across care settings to identify and address gaps in care.
• Implemented innovative programs and integrated care across the continuum for a high-risk population.

Main Results:

• Achieved a 50% reduction in hospitalizations for patients with chronic diseases.
• Supported patients with diabetes, resulting in a 12% reduction in HbA1c levels.
• Reduced readmission rates for patients completing pulmonary rehabilitation from 24% to 2.7%.

Conclusions:

• The transitional care nurse model successfully created an accountable community of health.
• This integrated care approach significantly lowered costs while improving care quality and patient satisfaction.
• TCNs are effective in bridging care gaps, improving teamwork, and enhancing outcomes for high-risk populations.