Redefining the future of health transitions
Meeting the complex health care needs of individuals living with chronic illnesses such as heart failure, diabetes and depression in a person-centered, safe, and efficient manner will be a, if not the, dominant healthcare challenge in the next few decades. Our research agenda focuses on the growing population of chronically ill adults with a specialization on frail, elderly adults and their family caregivers. Members’ implementation of various research methods is now creating a body of knowledge that will directly benefit this vulnerable population.
Southwestern Vermont Medical Center (SVMC) embarked on their Transitional Care journey in 2013 by redeploying and preparing acute care Clinical Nurse Specialists from the ICU, ED and Telemetry units.
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.