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Membership Continuing Education
Utilizing Transition Guide Nurses to Facilitate Patient Transitions and Reduce Readmissions

Publication Date: 9/6/2024


Length: 57 minutes, 31 seconds

Content Level: 1 Intermediate, General CE

Abstract
The Transition Guide program represents a true collaboration between the hospital and its health system home care group to support patients discharging from the hospital, specifically those not eligible for (or accepting of) skilled home care or a subacute facility. The Early Screen for Discharge Planning (ESDP) screening tool was employed to identify patients who need support upon discharge and are at higher risk for readmission. Patients most often served by this program have been assessed to be at risk for readmission due to lack of health insurance and access to ongoing primary care, inconsistent management of chronic illness at home, absence of pharmacy coverage or income to pay for medication, homelessness, mental illness and active substance use. Transition guide nurses are embedded within and are considered a central part of the hospital-based care management team. This session provides information to replicate this program at other settings and performance outcome metrics are reviewed.

Learning Objectives
1. Identify three screening tools used to identify patients at risk for readmission or other safety risks.
2. Describe how the success of the Transition Guide program is measured.
3. Discuss how the Transition Guide program's flexibility has led to its success.
4. Identify the partnerships necessary when assisting a patient safely through transitions of care.

Speakers:
Steven McGaffigan, LCSW-C, ACM-SW | Executive Director, Care Management and Social Work | The Johns Hopkins Hospital

Steven McGaffigan completed his MSW at Saint Louis University and is a Licensed Clinical Social Worker and a Certified Case Manager. He has led successful care management program redesigns that support proactive, evidenced-based, accountable and collaborative patient care. His experiences include hospital and health system care management department leadership roles in academic, safety-net, urban and rural settings. Steven is skilled in building hospital care teams and cross-continuum partnerships in support of strategic objectives. He is past national President of the American Case Management Association and past chapter President for the State of Florida.

Laura Syron, MSN, MPH, RN | Clinical Manager, Transition Guide Program | Johns Hopkins Home Care Group

Laura Syron completed her BSN at Catholic University and obtained her MSN and MPH from Johns Hopkins University. Her nursing practice has focused on community health and home care, ensuring patients are healthy and safe in their homes and communities. For the last 11 years, Laura has worked to improve patient safety during the transitions between levels of care.

Keywords: readmission, transitions of care

Utilizing Transition Guide Nurses to Facilitate Patient Transitions and Reduce Readmissions

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