Transitional Care Services

The Transitional Care Services program helps patients lower their risk of readmission to the hospital with the aid of a transitional nurse navigator (TNN).

The TNN shows patients how to maintain their best health after they are discharged. Patients get help managing chronic diseases like heart failure, COPD and diabetes in their home or residential care settings.

How Transitional Nurse Navigators Help With Care

The TNN serves as the primary liaison between the patient and the entire care team. They work closely with doctors, facilities, local agencies and community resources to support what each patient needs. Key services the TNN provides include:

Care Coordination

• The TNN completes a needs assessment and care plan for each patient to address their physical, psychosocial, spiritual and social needs.
• As a patient advocate, the TNN collaborates with primary care and specialty providers and with staff in appropriate community agencies.
• The TNN connects patients and their family members or other caregivers with community resources and services.

Follow-up

• The TNN follows through on what is outlined in the patient's care plan, including making appointments, getting medications and providing referrals to community agencies.
• They make sure patients understand and follow their medication orders.

Education

• The TNN provides education to patients and families beyond what they already get from the patient's doctor.
• The educational tools for each patient are suited to their specific needs.

Enrollment in Transitional Care Services

Patients are identified before being discharged from inpatient care at UM Shore Medical Centers at Chestertown and Easton and from all four UM Shore Regional Health emergency departments. They are screened for the presence of chronic diseases (including COPD, heart failure and diabetes) that would make them "high-risk for readmission" based on hospital and/or emergency department use, medical complexity and/or medication non-compliance. Patients who meet the criteria for follow-up after discharge are assigned to a TNN serving their location.

Contact Us

Questions about the Transitional Nurse Navigator Program may be directed to Jessica Denny, PT, DPT, 410-829-5504, jdenny@umm.edu.