CINHC Application Cover Page

AUTHOR Michelle D. Kelly RN, FNP, DNP(c)

ABSTRACT wish to be considered for Oral and Poster presentations

TITLE Infusing Care Transition into Nursing Courses:

plug and play toolbox for educators
AUTHOR/ Michelle D. Kelly RN, FNP, DNP(c)
Email: michelle.kelly@sonoma.edu, tel. 707-498-7773

ABSTRACT wish to be considered for Oral and Poster presentations

TITLE Infusing Care Transition into Nursing Courses:

plug and play toolbox for educators

Background and significance

When educators provide student with real world skills, clients benefit. Students need to master
the skills necessary to provide a safe transfer clients from hospital to home. Rising rates of chronic
disease, as well as an aging population, creates the demand for effective and safe transitions as
clients seek health care from a multitude of sources. We know these health care consumers face
an increased risk of avoidable readmissions. Medicare recently changed the re-imbursement
criteria for coverage of readmissions and denies payment for any 30-day readmissions that are
considered preventable. The demand is there for nursing graduates to better prepare clients for
self-care.
In a randomized control study, rates of readmission were decreased using the Coleman model.
This intervention is a low resource, yet, proven evidenced-based model. Eric Coleman’s Care
Transition model reduces 30-day readmissions in older adults. This interactive presentation will
provide ready-to-use educational tools adopted from Coleman’s model. The aim is for educators to
use the care transition tools to create real world opportunities for students to become competent in
assuring safe care for clients after hospital discharge. The Care Transitions model presents
educators an opportunity to incorporate contemporary research into nursing practice, which in turn,
improves quality and benefits clients.

Descriptions of methods and procedures

Oral and Poster Presentation will cover:
Overview of the problem of readmissions-
What are preventable readmissions and what can nurses do about it.
Introduction of Coleman’s Care Transition Model
Description & evidence of impact on clients
Educators Care Transition Toolbox
Existing online resources & demonstration

Results or outcomes
By the end of the presentation the audience will: understand the nursing role in preventing
readmissions; know about the tools available to them and be able to link care transition core
classroom or clinical content.

Conclusions/impact on patient care

The result of infusing care transitions into nursing education will foster competent graduates that
are able to practice in today’s dynamic healthcare environment. Students will coach clients to be
more active co-managers of their own care using Coleman’s model. Clients who are knowledge
able about their condition and medication are less likely to be readmitted.

2
Bio Sketch
Michelle Kelly, RN, FNP, DNP(c) is a community-based practitioner and nurse educator. She has
successfully coordinated a care transition program based on Coleman’s model with BSN students.
Kelly has cared for populations with chronic disease in rural communities in need of service and
where geographically beyond home health coverage. She found a way to involve students in
providing some of these health services. Students learned quality-improvement measures while
coaching people recently discharged from the hospital. Future endeavors will involve creating a
Care Transition Advisory Group and implementing an online Care Transition Learning Module for
nurses.