Secondary Logo

Journal Logo

Institutional members access full text with Ovid®

A Transitional Care Model Using Faith Community Nurses

Ziebarth, Deborah; Campbell, Katora P.

doi: 10.1097/CNJ.0000000000000255
Feature: parish nursing/practice

ABSTRACT: 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.

Deborah J. Ziebarth, MSN, RN, is a PhD candidate at the University of Wisconsin, Milwaukee School of Nursing, and Manager of Research and Special Projects at the Church Health Center, Memphis, Tennessee. Deborah and Katora developed the Faith Community Nurse Transitional Care Curriculum at the Church Health Center.

Katora P. Campbell, DrPH, RN, is the Director of Faith Community Outreach and the International Parish Nurse Resource Center at the Church Health Center, Memphis, Tennessee. She has over 17 years of managing faith community nursing programs.

The authors declare no conflict of interest.

Accepted by peer-review 10/19/2015.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of the article at; active links are provided in the iPad version.

For more than 30 additional continuing education articles related to faith community nursing, go to and search “faith-community nurses.”

© 2016 by InterVarsity Christian Fellowship