Effective care transitions can mean the difference between successful recovery from an illness or surgery and a patient who bounces back the hospital or rehab center because of a problem or acute condition change. To improve care transitions, PHI International, working with Trinity Health Senior Communities, has developed an advanced Certified Nursing Assistant (CNA) role called a “Transition Specialist” to provide continuity and assurance as a patient moves through the care continuum. The goal of these interventions will be to reduce hospital readmissions, improve patient satisfaction, and enable a safe move home after rehab and recover. Training for these specialists include topics related to chronic diseases such as diabetes, chronic obstructive pulmonary disease, and congestive heart failure. Read the full article.
