Transition Care Management Role & Process

In person and telephonic nurse visits to hospitalized CCH patients

• Assess understanding of diagnosis and hospital plan of care
• Educate and coach to promote health literacy and self-efficacy
• Identify social determinants of health and barriers to care
• Develop patient centered goals and care plan
• Provide advocacy, mobilize resources, and connect to services

Actively collaborate and coordinate patient care with hospital care team

• Facilitate hospital to primary care provider communication
• Update hospital care manager of TCM hosp visit and scheduled follow up

Coordinate access to CCH integrated care team for medical, mental health, and substance use disorder needs

• Schedule follow up appt with CCH provider before discharge
• Inform PCMP of hospital course, summary of care, and follow up needs

Objectives

• Coordinate transitions from hospital to community, respite care, and primary care
• Reduce hospital utilization and readmission through increased primary care engagement
• Participate in program development and partner collaborations
• Identify high risk hospitalized clients within primary care population and manage ongoing dynamic panel

CCH Transition Care Management (TCM) Nurses

Kiera Davis, RN	Carla Mickelson, Nurse Manager