The Visiting Nurse Service of New York City, in partnership with Mt. Sinai Medical Center, has implemented a transitional care model that integrates the role of a Nurse Practitioner across acute, primary, and home care settings. Designing a model and testing a complex set of strategies between microsystems over two years resulted in a reduction in pre- and post-hospitalization episodes for high-risk patients. This session describes the model, strategies, improvement opportunities, measures, and future applications.

After this presentation you will be able to:

• Describe a model of transitional care integrated across acute, primary, and home care settings.
• Identify specific strategies that resulted in a reduction in hospitalization episodes for a high-risk population, stratified by a predictive model.
• Define the rapid medical response role of a nurse practitioner functioning across inpatient, outpatient, and home care settings.
• Explore a business case for the transitional care model and future applications.