Transitional Care

Care Coordination to Reduce Hospital Readmissions


  • HTPN Advanced Practice Nurses (APNs) perform transitional care interventions with elder patients, 65 years or older, who are hospitalized for heart failure. Our APNs collaborate with Baylor physicians and staff to manage the discharge planning process of patients diagnosed with congestive heart failure. The patient and their dedicated NP, together, review heart failure information packets and set mutually agreed upon goals for post-discharge treatment plans. Follow-up care is provided through home visits and phone calls. Our Transitional Care program is a care coordination model that addresses the need to reduce hospital readmission rates and effectively manage the growing number of chronically ill patients that are beginning to appear in our patient panels. Results of our interventions have shown a significant reduction in 30-day readmissions from 25% to 9%.

  • transitional