Seattle-Denver Center of Innovation (COIN)
Rural Transitions Nurse Program (TNP)
The Rural Transitions Nurse Program (TNP) is a proactive, personalized, nurse-led, and Veteran-centered intervention, designed to improve the care coordination and transitions management for Rural Veterans discharged from a VA hospital.
TNP was piloted at the Denver VA Medical Center from 2014 - 2016. Veterans enrolled in TNP experienced significantly higher rates of communication and follow up with their VA PACT (Patient Aligned Care Team), and had fewer hospital readmissions.
The interventions of TNP are conducted with the help of a Transitions Nurse who completes four standardized core components, known as F.I.F.E.F Follow-up appointment coordination with PACT Clinic (within 14 days of discharge)
I Intervene to assess patient discharge readine
F Follow up post discharge call to patient
E Engage the rural Primary Care Provider (PCP) and PACT Clinic
Meet our staff
Review our program materials
Email us your feedback about the program
Watch our brief video
(TNP Video Transcription)
“What I could not coordinate in years, she put in place within a very short period of time. This kind of in-house proactive patient advocacy that reaches out to solve problems for Veterans living in distant or rural communities is outstanding and I could not be more thankful... Thank you for taking the risk to change the model and become more patient centric rather than hospital centric. Please consider this my vote for making your pilot program permanent and please add more Transition Nurses.”—letter from a Veteran