BookBillie Lynn Allard.
Contents:
Cover
Endorsements
Title Page
Copyright Page
Dedication
Acknowledgments
About the Author
Contributing Authors
Table of Contents
Preface: A Note From the Chief Financial Officer
Foreword
Introduction
Part 1: The Road to Inspire
Chapter 1: Healthcare Reform in the U.S.
Chapter 2: Answering the Call for Change
Chapter 3: Laying the Groundwork for a Transitional Care Nurse Program
Chapter 4: Piloting theTransitional Care Nurse Program
Chapter 5: Challenges and Roadblocks Appendix B: Transitional Care Nursing
Appendix C: Role Clarification for: Hospital-Based Case Manager, Blueprint for Health Medical Home Nurse Case Manager, Transitional Care Nurse
Appendix D: Transitional Care Nurse Orientation
Appendix E: Transitional Care Launch
Appendix F: Examples of Patient Education Tools Created by Interdisciplinary Team Focused on Care Coordination for COPD
Appendix G: Structure to Maximize Efficiency for ID Rounds Held Daily at 9 a.m. to Review All Inpatients in Med Surg, ICU
Appendix H: Brochures for Transitional Care Program Appendix I: Transitions of Care Annual Reports
Appendix J: Community Care Team Annual Reports
Appendix K: Community Care Team
Appendix L: Pediatric Community Care Team Annual Report
Appendix M: Pulmonary Rehabilitation Reports
Appendix N: Diabetes Education Annual Reports
Appendix O: Medication Therapy Management Annual Report
Appendix P: Youth Screening, Brief Intervention, Referral to Treatment (YSBIRT) Age 12-24 Years
Appendix Q: Pediatric Community Care Team
Appendix R:Transitions of Care Program Consent Forms Chapter 14: Inspire: Decreasing Hospital Readmissions From Skilled Nursing Facilities
Chapter 15: Inspire: The Clinical Pharmacist and Medication Management
Chapter 16: Inspire: Pediatric Community Care
Chapter 17: Inspire: Management of the Diabetic Patient
Chapter 18: Inspire: Physical Therapy Evaluation in the Emergency Department
Chapter 19: Inspire: Palliative Care Program
Chapter 20: Community Projects
Appendix A: Mapping Out Workflows With Community Partners: Strategy to Build Teamwork,Trust, and Accountability With Blueprint for Health Chapter 6: Evaluating and Addressing Highest-Priority Care Transition Needs
Chapter 7: Getting the Chief Financial Officer to Buy In
Chapter 8: Creating Successful Partnerships
Chapter 9: Compliance and Regulatory Concerns Associated With Transitional Care Nursing Programs
Chapter 10: Documentation and Data Management
Chapter 11: Spreading the TCN Program and Inspire Model Across the Profession
Part 2: Inspire Across the Care Continuum
Chapter 12: Inspire: Mental Health and Substance Abuse
Chapter13: Inspire: Pulmonary Rehabilitation for Patients With COPD