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Team collaboration at Northside

Nurses, pharmacists, social workers, respiratory therapists, physical therapists, dieticians and physicians collaborate daily to provide high quality care to COPD and PNA patients in their transitional care program. 

A little over 2 years in operation, the Transitions of Care program at Northside Hospital health care system serves patients 65 years of age and older who are discharged with chronic obstructive pulmonary disease and pneumonia. The program applies evidence based best practices to improve the health outcomes and reduce readmissions for a growing number of frail older adults in the Atlanta metropolitan area. Cristiane Fukuda, RN, MSN, ANP-BC, PMC, the Clinical Outcomes Manager shared that the support for the program originated fundamentally as “the right thing to do for the patients…as the population ages, we will have more high risk patients and will demand more investment in post-acute care transitions.”  Fukuda added she would like to expand the program to “include all 65+ patients independent of diagnosis.”