A Transitional Care Model Using Faith Community Nurses

In Brief The Medicare mandatory readmission reduction program has hospitals scrambling to reduce 30-day readmissions. A Faith Community Nurse (FCN) Transitional Care Model was developed from systematic literature review of predictive factors of readmission and pre- and postdischarge interventions that decrease readmission. The model presents specific FCN care that occurs pre- and posthospital discharge to support the patient in transitioning from one level of care to another, move toward wholistic health, and avoid unnecessary readmission. Hospitals are working to decrease readmission rates to save money and improve reimbursement. Discover an innovative evidenced-based model to decrease readmissions using faith communities.