This session describes how a community-based case management program of advanced practice nurses and social workers addresses the needs of vulnerable adults at high risk for readmission due to complex medical conditions…
Access to primary care services is a central component to a patient’s successful transition after a hospitalization or an emergency department (ED) visit…
Transitional care management (TCM) is a primary care service, and the payment model agrees. The inpatient setting is penalized for readmission, whereas the primary care setting is rewarded. This poster will shine a spotlight on why and how ambulatory care nurses must lead the TCM process…
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