Case Study: Southwestern Vermont Medical Center Transitional Care Nursing Program

Southwestern Vermont Health Care. Bennington, Vermont (SVHC) partners with Dartmouth-Hitchcock Health and is an integrated non-profit health system that includes a 99-bed hospital, 25 primary care and specialty care practices, and two nursing homes. SVHC serves more than 70,000 people in the towns and villages of Bennington County, western Windham County and southern Rutland County in Vermont; eastern Rensselaer County in New York; and northern Berkshire County in Massachusetts.

Patients often transition between clinicians or settings during the course of their illness. Hospital to home or hospital to nursing facility are just two examples and they can be a vulnerable time for patients. They are also a challenge to manage, especially when medically complex. Poorly executed care transitions can lead to bad outcomes like unnecessary readmissions and lower quality of life for patients. They also result in unnecessary costs.

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