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Transition CMs reduce readmissions from SNFs.

At Western Maryland Regional Medical Center, having nurse transitionists act as a liaison between the hospital and nursing facilities has reduced the readmission rate from participating facilities from 30% to 18%. The nurse transitionists carry a caseload of about 70 patients and work closely with the nursing home staff, patients, and family members to improve transitions. They follow patients who are admitted from a skilled nursing facility from the time they are admitted and patients who are going to a skilled nursing facility for the first time from the time that they are accepted into a bed and for 30 days after discharge. They visit the nursing home within 24 hours of transfer, meet with the patient, family, and staff and answer questions.They return on Day 5, between Day 11 and Day 14, and again at 25 to 30 days.