COIN TNP - Seattle-Denver Center of Innovation (COIN)
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Seattle-Denver Center of Innovation (COIN)


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Rural TNP Staff

The TNP program staff is based in Denver. We support the Transitions Nurses through ongoing training in care coordination, effective communication, leadership, followership, executive presence, presentation and self-care skills. We problem solve operational issues and host a peer-to-peer learning collaborative that meets bi-weekly to discuss Veteran and organizational issues. The implementation and evaluation team support adoption and sustained use of the TNP intervention through facilitation, audit and feedback, and the creation of program materials, reports, and marketing materials. TNP is evaluated using a mixed-methods approach, guided by the RE-AIM and PRISM frameworks.

Operations Team:

Lynette Kelley, FNP

Picture of Lynette Kelley

Lynette is a family nurse practitioner and nurse researcher at the Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care at the Rocky Mountain Regional VA Medical Center. She works as the Clinical Director/Implementation Scientist as well as clinical consultant to support quality improvement care coordination programs. Her involvement includes nurse training curriculum development, process improvement and implementation of innovative interventions. Lynette was the first Transitions Nurse from program initiation in 2014. She earned her MSN-FNP from the University of Colorado at Colorado Springs and is passionate about improving the quality of care and patient experience of the Veteran population.

Ashlea Mayberry - RN

Picture of Ashlea Mayberry

Ashlea is a program manager and implementation specialist on multiple care coordination quality improvement programs at the Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care. Ashlea received a bachelor degree in nursing from the University of Notre Dame Australia where she practiced clinically for 6 years before moving to Denver, Colorado. Her interests include clinical education and improvement of implementation processes.

Implementation and Evaluation Team:

Chelsea Leonard, PhD

Chelsea Leonard is an Anthropologist and qualitative methodologist at the Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care at the Veterans Health Administration in Denver, CO. She leads the evaluation for the rural Transitions Nurse Program. Her research interests include healthcare decision making and the role of observation and ethnography in health services research.

Marina McCreight, MPH

Picture of Marina McCreight

Marina is a Health Science Specialist at the Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care at the Veterans Health Administration in Denver, CO. She is also an implementation coordinator and a qualitative analyst. Her research interests include process improvement and implementation and evaluation of evidence-based health services interventions.

TNP Nurses:

Jeanne Caldwell

Picture of Jeanne Caldwell

Jeanne is a Registered Nurse, Transitions Nurse with the Transitions Nurse Program at the Rocky Mountain Regional VA Medical Center in Colorado. She is a graduate of the University of Colorado Health Science Center School of Nursing, University of Colorado Graduate School of Public Affairs, with over 24 years of nursing experience in acute hospital, home-health and long-term care. Her interest include quality improvement for patients who are at health risk and implementation of quality improvement interventions.

Brigid Connelly, BA – Professional Research Assistant

Picture of Brigid Connelly

Brigid is a Professional Research Assistant working on many quality improvement programs at the Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care since December 2018. She received her Bachelor’s degree in Psychology from Colorado College in 2017. Following graduation, Brigid worked on substance abuse and drug research before joining the COIN. Her interests include trauma and the administration of care following violence or a traumatic event.

Shelby Flint

Picture of Shelby Flint

Shelby is the Rural Transitions Nurse in Portland Oregon. She has been an RN at the Portland VA Healthcare System for 15 years. She earned her bachelor’s degree from Linfield College, and Master’s degree from Gonzaga University. Shelby has a wide range of experience within the VA as a nurse in Critical Care for many years, educator, preceptor and mentor for nurses across the continuum.

Susan Gluth

Picture of Durham VA hospital

The TNP is no longer available at this site. Please contact the facility directly regarding any care coordination needs. Previous Transitions Nurse – Susan Gluth

Christine (Tina) M. Griffel MSN, CCCTM, RN-BC

Picture of Tina Griffel

Christine Griffel received her Masters of Science in Nursing from Carlow University in Pittsburgh, Pennsylvania. Additionally, Christine is Certified in Care Coordination and Transition Management (CCCTM), Ambulatory Care, Medical/Surgical and Gerontology. Currently, Christine represents the Veterans Administration Pittsburgh Healthcare System (VAPHS) serving as a Rural Transition Nurse in the Transition Nurse Program. Christine is also the VAPHS Whole Health Lead. In this role she educates staff to Whole Health and precepts Whole Health coaches in their new role. As an active member of the American Academy of Ambulatory Care Nursing she has participated in several taskforces to include the CCCTM Core Curriculum Review Team and has served as a question writer for the CCCTM Review Questions. Most recently, Christine participated as a task force member for the 6th Edition Scope and Standards of Practice for Professional Telehealth Nursing. Christine appreciates the Veteran population she serves and especially loves being a VA nurse.

Dawn Harris

Picture of Gainesville VA hospital

The TNP is no longer available at this site. Please contact the facility directly regarding any care coordination needs.
Previous Transitions Nurse – Dawn Harris

Lisa J. Irwin

Picture of Lisa Irwin

Lisa has been employed by the Iowa City VA Medical Center since October, 2005 with experience in Intensive Care Unit, Palliative/Hospice Care and Surgical Discharge Coordinator. In July, 2017, she became the Iowa City Rural Transitions Nurse Coordinator. She is very passionate about successful discharge coordination in effort to reduce length of stay and readmission rates.

Mary Ava Nunnery, MPH - Health Science Specialist

Mary is a Health Science Specialist on a care coordination quality improvement program and pain studies at the Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care. Mary received her Masters of Public Health with a specialization in behavioral health in 2018. Her interests include communication styles, community engagement, and holistic care for veterans.

Elizabeth (Lisa) R. Ordway

Picture of Lisa Ordway

Lisa is the Rural Transition Nurse at the Puget Sound VA in Seattle. She was a critical care nurse for eleven years prior to the TNP initiation at her facility, and has been an adjunct faculty member for the Seattle Community Colleges nursing program for the past ten years.

Principal Investigator:

Heather M. Gilmartin, PhD, NP

Picture of Heather M. Gilmartin, PhD, NP

Dr. Gilmartin is an investigator and nurse scientist with the Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VA Eastern Colorado Healthcare System, an assistant professor at the University of Colorado, School of Public Health, and adjunct faculty at the University of Colorado, School of Nursing. Her research focuses on understanding and optimizing the culture of healthcare to enhance patient safety, transitions of care, and facilitate organizational learning. She earned her PhD in Nursing and Health Systems from the University of Colorado and was a VA Post-doctoral Nurse Fellow. In 2016, she joined the Denver-Seattle Center of Innovation. She has been part of the rural Transitions Nurse Program since the beginning. First as the lead for the implementation science and evaluation aspects. Most recently, she has taken over the role of principle investigator.

TNP Creator
LDI Senior Fellow

Robert Burke, MD, MS, FHM

Assistant Professor, Medicine, Perelman School of Medicine
Picture of Robert Burke

Dr. Burke is the first Director of Research for the Hospital Medicine Section at the University of Pennsylvania and an Assistant Professor of Medicine at the Perelman School of Medicine. Dr. Burke's research seeks to improve the outcomes associated with transitions from the hospital to post-acute care in vulnerable populations. For example, his VA Career Development Award seeks to understand and improve processes of care that influence outcomes of these transitions, and he has been funded by the National Institute of Aging to understand provider and patient decision-making regarding post-acute care in skilled nursing facilities in order to better anticipate the benefits and harms of PAC for individual patients at the time of hospital discharge. He also works on large-scale dissemination and implementation projects, such as the rural Veteran Transitions Nurse Program, and is active in quality improvement work locally and as an Associate Editor for BMJ Quality & Safety. Dr. Burke was selected as a 2017-8 Health and Aging Policy fellow working with the Centers on Medicare and Medicaid Services on programs for dual-eligible populations. Dr. Burke matriculated from Stanford University of School of Medicine and completed residency training in internal medicine at Brigham and Women's Hospital in Boston. From 2011-2018, he served as an Assistant Professor at the University of Colorado and as a hospitalist at the Denver VA Medical Center, completing a Masters degree in Clinical Sciences at the University of Colorado in 2015

TNP Team Movements

Rural TNP staff at Roseburg VA
TNP team on a pre-implementation site visit at Roseburg, OR

Meet the Team