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

presented by Barbara Lutz & Michelle Camicia

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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

  • 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 as they move through the continuum of care, from acute care to home. The goal of her work is to engage patients and their family caregivers in developing person and family-centered, community-based interventions for people with stroke and other chronic illnesses. She is a Co-Investigator on a PCORI-funded research study to test a person-centered, community-based Emergency Department (ED) to Home transitional care intervention developed in partnership with a research team that includes former patients, family caregivers, social workers, ED physicians, staff of two local Area Agencies on Aging, and health services researchers. Dr. Lutz is a Fellow in the American Academy of Nursing, American Heart Association (AHA), and National Academies of Practice. She is a board member of the Association of Rehabilitation Nurses and is a co-author on a position paper on the transitional care needs for patients needing rehabilitation services and on AHA scientific statements on palliative care in stroke, risk adjustment for stroke, and best evidence on stroke caregiver interventions. She has also served as a member of the ANA Care Coordination Quality Measures Steering Committee and as a rehabilitation expert on the Joint Commission Technical Advisory Panel for Comprehensive Stroke Center Certification.

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  • Michelle Camicia, PhD, MSN, RN, CRRN, CCM, NEA-BC, FAHA

    Michelle Camicia, PhD, MSN, CRRN, CCM, NEA-BC, FAHA, 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, in addition to providing outreach, quality, and regulatory oversight. Michelle is a past president of the Association of Rehabilitation Nurses. She has participated in numerous national and international advisory panels and committees related to professional nursing practice, rehabilitation, and health care reform, and has published 13 peer-reviewed publications. Michelle currently serves on the National Institutes for Health National Advisory Board for Medical Rehabilitation Research, the National Quality Forum Neurology Standing Committee, and the Editorial Board of Rehabilitation Nursing, and is Chair-elect of the American Heart/Stroke Association International Stroke Conference State-of-the-Science Symposium. Michelle recently finished her doctorate in nursing and health care leadership program at The Betty Irene Moore School of Nursing at the University of California, Davis. She is studying the predictive validity of the Preparedness Assessment for the Transition Home after Stroke (PATH-s), a novel instrument she developed with a colleague to assess stroke caregivers' commitment and capacity for the caregiving role.

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Chapters & Learning Objectives

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  1. Nursing Assessment and Planning

    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

    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

    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.