Transitional Care Nursing (TCN) Services

Hospital readmissions for patients with chronic obstructive pulmonary disease (COPD), heart failure (HF) and pneumonia have negative repercussions for the patient, the health care facility and the community it serves. Avoiding hospital readmissions for the primary and complicating conditions of COPD, HF and pneumonia, improving the health outcomes of patients after discharge and enhancing the patient and family caregiver experience are goals that align with the hospital's mission of providing exceptional care through a commitment to clinical excellence and compassion for every patient, every day.

Instituting transitional care nursing (TCN) services has provided patients with added support for their transition from hospital to home, successfully preventing unnecessary readmissions. This support includes education and coaching for medication understanding and management, and self-management of a patient's condition, including the importance of follow-up and communication with their health care providers. Those enrolled in TCN have realized a readmission rate of 8.16 percent, compared with 16.55 percent for those patients declining this free service.

This case study is part of the Illinois Health and Hospital Association's annual Quality Excellence Achievement Awards. Each year, IHA recognizes and celebrates the achievements of Illinois hospitals and health systems in continually improving and transforming health care in the state. These organizations are improving health by striving to achieve the Triple Aim—improving the patient experience of care (including quality and satisfaction), improving the health of populations, and reducing the per capita cost of health care—and the Institute of Medicine's six aims for improvement—safe, effective, patient centered, timely, efficient, and equitable. To learn more, visit https://www.ihaqualityawards.org/javascript-ui/IHAQualityAward/