experience the role of a graduate degree prepared nurse who is a Patient Care Transition Coordinator. For the purpose of this CPE, a Patient Care Transition Coordinator is defined as a nurse who focuses on assisting patients moving from the hospital to a rehabilitation facility, and then to their homes. During this experience, you will help specific patients move through different levels and types of care. You will identify the education, experience, and skills required for you to perform this role successfully. Additionally, as a Patient Care Transition Coordinator, you should aim to prevent hospitalization and rehospitalization of patients who returned to their homes after hospitalization and rehabilitation.
In this CPE, you will experience the role of advanced professional nurse in the transitions of care from hospital to home or sub-acute or chronic facility.
The task is comprised of three phases of the transitions of healthcare continuum for a patient. You will examine and discuss evidence-based practices for a selected patient with one of the conditions or procedures identified by the CMS Hospital Readmissions Reduction Program (HRRP). Patient scenarios for each of the conditions or procedures follow the instructions.
The three phases on which you will focus are:
• Transition from hospital to home or sub-acute care facility
o Discuss the HRRP readmission reduction plan.
o Provide introduction to your patient and discuss pre-discharge initiative/interventions to promote optimal recovery and prevent readmission within 30 days or less.
