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In Focus with Eileen Brinker

We connected with Eileen Brinker, RN, MSN, Clinical Coordinator for the MIRROR-TCM trial based in the Office of Population Health and Accountable Care at UCSF Health, to discuss the complex health and social needs patients experience and the importance of care continuity in meeting those needs through engagement, communication, education, and the strength of a well-built team.

Among her contributions to date as a nurse innovator, Brinker is leading a clinical team in the delivery of the Transitional Care Model (TCM) at UCSF Health. Collectively, their efforts are focused on improving the care and health outcomes of medically complex older adults who are hospitalized and discharged to the community. Brinker remarked how the TCM is represented in the overarching P.R.I.D.E. (Professionalism, Respect, Integrity, Diversity, Excellence) values at UCSF Health that sets a high standard of quality for how all team members at UCSF collaborate to fulfill their mission of advancing health.

The TCM was designed to stop the revolving-door crisis of hospitalizations that occurs far too often when older adults experience a change in health status. Some hospitalizations cannot be avoided and are necessary, but many can be prevented when an evidence-based care model is deployed effectively. Brinker’s enthusiasm for UCSF Health’s participation in the MIRROR-TCM trial is informed by her extensive inpatient clinical experience, where for more than a decade she was responsible for engaging patients and their families in understanding their condition and the care they receive. Now as she and the team at UCSF Health implements the TCM, the connection made with patients in the hospital systematically extends into the community and provides clinicians with critical contexts that may help prevent at-risk patients from experiencing a readmission. Brinker shared they have already seen the impact of the model at UCSF Health through requests for referral to the TCM program by other clinical units and departments. (Note: the RCT protocol is in effect and no referrals are accepted.) Further, Brinker discussed how the difference is being made through the TCM program is by an advanced practice registered nurse, prepared by the Penn team architects to deliver the TCM, who “…see[s] the challenges in the hospital, they optimize the discharge, they work with the medical team, the case managers, the family, to advocate for that patient, and then they continue with the patient home. Then they see that patient’s progression from the hospital to home, and then over the next two to three months, whether it’s a decline or it’s an improvement. Having one person do all of that is the game changer.”

The TCM takes a wholistic look at what brought a patient to the hospital and how future hospitalizations can be prevented when gaps in care are eliminated. However, no community or health system was prepared for a global pandemic. Like other academic health systems, UCSF Health is embedded in a large, highly diverse community with a growing population of older adults whose health and social needs have been impacted by the COVID-19 pandemic. As many older adults live alone, they were further isolated due to quarantine-containment efforts because of limited or no access to internet or the devices needed to engage in virtual visits. It was vitally important to the Population Health team and other teams to make telephonic outreach to patients and partner with local groups to make additional calls to vulnerable patients as well. The disruption to essential supports (e.g., transportation; home health aides) also contributed to missed preventive care and delayed treatment seeking behaviors for fear of becoming infected. While many communities are “re-opening” and services are starting to resemble pre-pandemic access, there remains much that is unknown about the long-term effects of the virus from the past year. The Penn team and partnering health systems will continue to examine the impact of the virus on patients and implementation efforts.

Read the full interview


Eileen Brinker, RN, MSN, Clinical Coordinator for the MIROR-TCM study has worked at UCSF Medical Center for over 17 years. She worked as a bedside nurse on the cardiovascular unit for 5 years and as Heart Failure Program Coordinator/ Care Transitions Inpatient Program Manager for 12 years. Brinker developed and implemented an evidence-based Heart Failure Program that includes thorough patient education, follow up calls, discharge planning, and advocacy and support roles for the patient, family and caregivers. This program has resulted in a reduction of readmissions for their patients. It was chosen by the Institute of Healthcare Improvement (IHI) to be featured at the National Forum and included in IHI’s “How-to-guide: Creating an ideal Transition Home”. Brinker enjoys spending time with her husband and their four children in the Bay area. She received her Bachelor’s at Santa Clara University and Master’s in Nursing from Samuel Merritt University.