Implementation of Transition in Care and Relationship Based Care to Reduce Preventable Rehospitalizations. (July 2015)

• Record Type: Journal Article
• Authors: Burt, Susan; Berry, Donna; Quackenbush, Patricia
• Is Part Of: Home healthcare now. Volume 33:Number 7(2015:Jul./Aug.)
• Publication Date: 2015-07
• Subjects: Community health nursing -- Periodicals; Home nursing -- Periodicals; Public health nursing -- Periodicals; Community Health Services -- Periodicals; Home Care Services -- Periodicals; Home Nursing -- Periodicals; Public Health Nursing -- Periodicals; Community Health Nursing -- Periodicals; Occupational Health Nursing -- Periodicals; Community health nursing; Home nursing; Public health nursing; Periodicals; 610.7343
• DOI: 10.1097/NHH.0000000000000269
• Languages: English
• ISSNs: 2374-4529

Abstract

Abstract : Home healthcare agencies are accountable for preventing rehospitalization, yet many struggle to make progress with this metric. The purpose of this article is to share how our organization turned to two frameworks, Transitions in Care and Relationship-Based Care, to prevent unnecessary rehospitalizations. Appreciative inquiry, motivational interviewing, and action plans are used by our Transitional Care Nurses to engage and motivate patients to manage chronic diseases and achieve desirable health outcomes. Implementation of a Transitional Care Program has led our organization to improve the health of our patients and to decrease rehospitalization rates.