Journal
CRITICAL CARE NURSING CLINICS OF NORTH AMERICA
Volume 27, Issue 4, Pages 537-+Publisher
W B SAUNDERS CO-ELSEVIER INC
DOI: 10.1016/j.cnc.2015.07.010
Keywords
Nurse navigator; Transitions of care; Self-management; Readmission rates; Heart-failure
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Today's health care systems are faced with challenges to transform health care delivery and provide quality and valued services for the heart failure population. These challenges require collaboration and the development of strategic processes that will redefine best practices. Implementing a multidimensional nurse navigator transition program is one approach to facilitating cross-continuum of care. Such a program has been proven to significantly reduce 30-day all-cause hospital readmissions, enhance self-management skills, and improve follow-up compliance. This transitional care model can be used to address the needs of all patients with chronic conditions.
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