The Opportunity for the Clinical Nurse Leader Role in Transitional Care Leadership

The purpose of this presentation is to describe the opportunity for leadership of the Clinical Nurse Leader (CNL) in transitional care. Leadership in transitional care is often missing resulting in any number of healthcare challenges related to errors and quality. For example, fragmentation and specialization result in problems in patient safety, medication administration, patient education, patient follow up, and gaps in communication. Typically, it is the chronically ill with the highest potential for frequent hospital visits due to the complexity of their healthcare illnesses. These hospital visits increase when there is miscommunication, breakdown in follow up, and/or lack of patient understanding. Transitions occur among patients, families, care providers, nurses, clinicians, physicians, hospitals, care settings and all along the care continuum. When problems around transitions occur it is costly for patients, families, healthcare providers, and healthcare payors which often results in unnecessary errors and poor outcomes.

The CNL would potentially bridge gaps 1) by participation of the CNL as navigators or coaches at the point of care and across the transitional care continuum and 2) as a leader in interprofessional transitional teams. This presentation will discuss the CNL skill set and its applicability in transitional care. In the United States (US) a variety of models of transitional care have been implemented in healthcare.

Research has demonstrated a positive impact of transitional care on health outcomes while reducing costs. In a recent transitions of care model, a southern California hospital utilized a CNL in the leadership role on a transitional healthcare team. Team members were identified as Health Care Coaches (HCC). Based on research of the characteristics needed, expectations, barriers and benefits of health care coaches, qualities and characteristics were identified. Interestingly, these characteristics aligned with the skill set of the CNL. Further, in this model the transitional healthcare team leader was a CNL. aligned with the skill set of the CNL. Further, in this model the transitional healthcare team leader was a CNL. Savings documented using this model in the southern California hospital were as follows: Medicare Fee For Service 30 Day Readmission Rate from June-November, 2013 at 12.77% however, with the patients enrolled in the transitional care model, the 30 Day Readmission Rate June-November, 2013 was 7.15%. The cost for a 30 day readmission event is $14,225, with the 12.77% versus the 7.15% yielding an annualized savings of over 2.3 million dollars in one hospital alone.

The CNL brings a skill set and competencies that support organizational processes in both the microsystem and macrosystem. These abilities are essential for coordinated and successful transitional care. The presentation will compare and contrast the CNL skills with the HCC and transitional care team leader.

This presentation will discuss several current models of care and the relationship to CNL competencies and education. Characteristics for HCC in transitions of care and the alignment of CNL competencies will be identified. The topic of models of transitional care is relevant to this conference because the CNL role in nursing is particularly suited to facilitate transitions of care for the chronically ill. The model of having the CNL role in transitional care leadership and the qualification of a skill set that fosters positive patient outcomes and decreases cost is a significant opportunity for nursing to contribute to improving healthcare and evidenced based practice. There is growing research on the role of the CNL as well as the need for smooth and uncomplicated transitions between care events and systems. Further, nursing has an opportunity for leadership with the CNL in transitional care.