Directs the Secretary to establish a Community-Based Care Transitions Program which provides funding to eligible entities that furnish improved care transitions services to high-risk Medicare beneficiaries.
Nurses are uniquely skilled and positioned to lead this initiative. Assessing needs; providing care; managing/directing care; communicating with interdisciplinary care teams; and educating patients, caregivers and other healthcare providers are competencies required to deliver Transitional Care in an effective and efficient manner. Additionally the nursing profession is adept at monitoring and analyzing outcomes of care.
In an effort to prepare nursing leaders to meet this challenge, knowledge of the scope of the issue and the success or limitations of existing models is key. Accessing the following list of resources will provide the nurse leader with a wealth of knowledge and implementation tools regarding this topic:
Agency for Healthcare Research and Quality http://www.ahrq.gov/ National Alliance Quality Care http://www.gwumc.edu/healthsci/departments/nursing/naqc/resources.html National Priorities Partnership http://www.qualityforum.org/Setting_Priorities/Addressing_National_Priorities.aspx Robert Wood Johnson Foundation (RWJF) and the Institute of Medicine (IOM) collaborative study the “Future of Nursing” Report Briefing: http://www.iom.edu/Activities/Workforce/Nursing/2010-OCT-05.aspx
Transitional Care http://www.transitionalcare.info/index.html National Institute of