Dr. J. Michael Leger
Dr. Maureen Biggs
School of Nursing
Transitional Care Management (TCM) programs have proven effective in bridging gaps across health care settings, particularly for patients deemed at high risk for poor medical outcomes. With an estimated 3,000 patients seeking medical treatment at the St. Vincent's House Nurse Manage Clinic annually, more than 17 percent of these patients are considered at-risk and often "fall through the cracks." To help with this problem, this project will provide for the services of a nurse transition care manager to facilitate a TCM program at St. Vincent's. The objective is to build a rapport with patients, provide disease-specific education to facilitate self-management, perform medication reconciliation, confirm follow-up appointments, and provide care management to support treatment.