Seattle-Denver Center of Innovation (COIN)
Rural Transitions Nurse
The rural Transitions Nurse Program (TNP) is a proactive, personalized, nurse-led, Veteran-centered intervention designed to improve the transitions of care for rural Veterans discharged from a VA hospital.
TNP was piloted at the Denver VA Medical Center from 2014-2016. Veterans enrolled in the Denver TNP experienced significantly higher rates of communication and follow up with their VA Patient Aligned Care Teams (PACTS), and had fewer hospital readmissions then matched Veterans not enrolled in TNP.
In 2017, TNP received funding to expand the program as a VA enterprise wide initiative through the Office of Rural Health, with support from the Office of Nursing Services. TNP is currently implemented at 10 VA facilities and has coordinated the care of over 3,500 Veterans from 77 PACT clinics.
TNP is an evidence-based intervention conducted by a Transitions Nurse based at a VA tertiary facility. The Transitions Nurse completes four key steps for every Veteran enrolled in the program to ensure an ideal transition of care. These four steps are known as F.I.F.E:
To learn more about the TNP program staff, the Transitions Nurse training program, implementation tools, evaluation methods and outcomes – please go to the program resources pages.
Thanks from TNP group