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Nursing’s Role in Care Transitions from Acute Care to Post-Acute Care

presented by Michelle Camicia, PhD, RN, CRRN, CCM, NEA-BC, FARN, FAHA, FAAN and Barbara Lutz, PhD, RN, CRRN, APHN-BC, FAHA, FNAP, FAAN

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Disclosure Statement:

Financial: Barbra Lutz is funded as a co-investigator through patient-centered outcomes research institute (PCORI) and national institutes of health. Michelle Camicia is funded by the Gordon and Betty Moore Foundation and the Rehabilitation Nursing Foundation


 Non-Financial: Barbra Lutz and Michelle Camicia have no competing non-financial interests or relationships with regard to the content presented in this course.

Satisfactory completion requirements: All disciplines must complete learning assessments to be awarded credit, no minimum score required unless otherwise specified within the course.

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This course gives students an overview of the nurse's role in facilitating care transitions for stroke survivors from acute care to post-acute care to optimize outcomes for the patient and family. Specific risk factors associated with poor transitions are presented. Participants will learn nursing interventions to optimize care transitions for stroke survivors. A brief review of evidence-based models of care transitions across the post-acute continuum will be provided.

Meet Your Instructors

Michelle Camicia, PhD, RN, CRRN, CCM, NEA-BC, FARN, FAHA, FAAN

Michelle Camicia, PhD, MSN, CRRN, CCM, NEA-BC, FAHA, FARN, FAAN, is the director of operations for Kaiser Foundation Rehabilitation Center at the Vallejo Medical Center. She is responsible for day-to-day operations of the Center as well as outreach, quality, and regulatory oversight. Michelle is a past president of the Association of Rehabilitation Nurses. She has…

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Barbara Lutz, PhD, RN, CRRN, APHN-BC, FAHA, FNAP, FAAN

Dr. Barbara Lutz is the McNeill Distinguished Professor at the University of North Carolina-Wilmington School of Nursing. Her 30+ year career as a rehabilitation and public health nurse spans practice, research, education, and service. Her research focuses on understanding the needs and experiences of patients with stroke and other chronic illnesses and their family caregivers…

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Chapters & Learning Objectives

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1. Nursing Assessment and Planning

Nurses need to recognize the risks associated with care transitions in order to contribute to the transition plan for stroke survivors. The importance of nursing assessment and the nurse’s contribution to the transition plan is described.

2. Care Transitions Models and Resources

Nurses need to understand the resources available for transitioning patients and their caregivers, as well as the Care Transition Models used to guide practice. This chapter reviews evidence-based care transitions models and provider and patient resources to optimize care transitions. Priorities for care transitions for differing stroke severity are described.

3. The Post-Acute Continuum of Care

Many stroke survivors utilize services in the post-acute care continuum. Factors such as criteria for admission and the scope and intensity of service are reviewed. Outcomes of stroke survivors served in the different levels of post-acute care are described.

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