Under the transitional care model, who typically coordinates patient care after discharge?

The transitional care model focuses on ensuring that patients receive continuous and comprehensive care as they move from one healthcare setting to another, particularly from hospital to home. Advanced Practice Nurses (APNs) play a crucial role in this system due to their advanced clinical skills, comprehensive training, and ability to provide patient-centered care.

APNs are equipped to assess patients holistically, manage complex health needs, and educate patients and families about their care plans. Their involvement in coordinating care post-discharge helps to minimize the risks of hospital readmissions and ensures that patients understand their medications, follow-up appointments, and self-care strategies.

While social workers, physicians, and care coordinators contribute to various aspects of patient care, the unique qualifications and practice scope of APNs make them particularly effective in leading the coordination of care after discharge within the transitional care model. Their expertise allows them to bridge the gap between different care settings and ensure an effective transition for patients.