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Overview of Care Transitions for Rehabilitation Nurses

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

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Disclosure Statement:

Financial: Michelle Camicia is funded by the Gordon and Betty Moore Foundation and the Rehabilitation Nursing Foundation


 Non-Financial: 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 is part of our CRRN(R) Prep-Program. Learn more about the full prep-program here: MedBridge CRRN(R) Prep-Program.

Care transitions for individuals with disabling conditions are often ineffective and inefficient, resulting in poor outcomes and financial burden to the care delivery system. Rehabilitation nurses can promote successful living in the community through facilitating safe and effective care transitions. This course provides an overview of care transitions, which includes case management, discharge planning, and community reentry. Community, personal, and professional resources are provided, and the nurse's role in assessing resource needs is discussed.

CRRN(R) is a registered trademark of the Association of Rehabilitation Nurses.

Meet Your Instructor

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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Chapters & Learning Objectives

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1. Care Transitions and Case Management

Case management is an effective means to improve the quality of transitions during the discharge planning and transition of individuals with disabling conditions across the continuum of care. The role of the case manager and a brief overview of models will be described.

2. Resources to Facilitate Care Transitions

The rehabilitation nurse has a breadth of skill to assess the need for and explore resources to facilitate care transitions. This chapter explores the resources to optimize care transitions. Community, personal, and professional resources to assist with discharge planning and community reintegration are described.

3. Practice Implications Related to Care Transitions

This chapter presents information on how nurses can influence care transitions through providing input into case management, discharge planning, and community reintegration. The various leadership competencies for rehab nurses to impact care transitions for persons with disability and/or chronic illness are described.

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