2022 Stronger - PH315 - Clinical Navigators: Facilitating Transitions of Care
Join us for a panel discussion about how two health care organizations incorporated navigator roles to smooth transitions of care from inpatient to post-acute and outpatient settings.
Michigan Medicine implemented a comprehensive transitions-of-care program that contributed to reduced readmissions. The program includes a bundled approach with centralized nurse and pharmacist contact before primary care appointments, as well as follow-up post-inpatient discharge to address clinical and medication-related questions. Results to date demonstrate decreased readmission rates for program participants versus nonparticipants.
Penn Medicine will share the evolution of its new transitions provider role that addresses identified care transition gaps for acute leukemia patients. An inpatient-based nurse practitioner serves as an expert consultant to the primary care team and patient while advancing care planning and facilitating a smooth transition out of the hospital. Results to date demonstrate reduced readmissions for this patient population. This quality improvement intervention creates a system that better supports patient care needs across the continuum and prevents essential elements from being overlooked.
Join the panelists to learn more about their successful transitions of care.
Target Audience
- Nurses
- Pharmacists
- Physicians
- Other Healthcare Professionals
Learning Objectives
- Describe a team-based approach to reduce admissions through a centralized, bundled, transitions-of-care program.
- Discuss how to identify and address team-based gaps in transitions of care from inpatient to post-acute and outpatient settings.
- Identify how to incorporate clinical navigator roles to smooth transitions of care between teams.
Additional Information
Attachment | Size |
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PH315.pdf | 1.55 MB |
Kathryn Allen, CRNP, AGACNP, Acute Leukemia Transitions Coordinator, The Hospital of the University of Pennsylvania, Philadelphia, PA
Erin Lightheart, MBA, CSSBB, PMP, Master Improvement Advisor, Penn Medicine, Philadelphia, PA
Colleen Kucharczuk, DNP, CRNP, Manager of Oncology Advanced Practice Providers, Penn Medicine, Philadelphia, PA
Hae Mi Choe, PharmD, Associate Chief Clinical Officer for Quality and Care Innovations, Michigan Medicine, Ann Arbor, MI
Michelle Neeley, Project Manager, Michigan Medicine, Ann Arbor, MI
Vikas Parekh, MD, Associate Chief Medical Officer and Professor of Internal Medicine, Michigan Medicine, Ann Arbor, MI
Disclosure
Credit Types
This activity was planned by, and for, the healthcare team, and learners will receive 0.75 Interprofessional Continuing Education (IPCE) credits for learning and change.
Nurses (CNE)
Vizient, Inc. designates this live activity for a maximum of 0.75 ANCC contacts hours.
Pharmacists (CPE)
Vizient, Inc. designates this live activity for a maximum of 0.75 contact hours for Pharmacists.
Universal Activity Number: JA0006103-0000-22-081-L04-P
Physicians (CME)
Vizient, Inc. designates this live activity for a maximum of 0.75 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Other Healthcare Professionals (General CE Credit)
Vizient, Inc. will award a maximum of 0.75 contact hours to all other healthcare professionals who successfully complete the activity. These individuals will receive a Certificate of Participation indicating the maximum credits available.
Many state licensing boards and credentialing bodies accept certificates of participation from accredited CE activities to meet CE requirements for license renewals and re-certification. It is the responsibility of the participant to contact their state licensing board and/or certifying body for verification on credit eligibility reciprocity.
Available Credit
- 0.75 ACPE Pharmacist
- 0.75 AMA PRA Category 1 Credit™
- 0.75 ANCC
- 0.75 General CE - Attendance