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.
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