Home Care Heroes Blog

Care Transition Nurse Explains Her Role

The following post was shared by Housecall Providers of Portland, OR.  Housecall Providers has embraced the concept of healthcare at home and they provide primary care, transitional care services as well as hospice and palliative care in their community.  Their website features stories that can help provide inspiration to home care organizations who aspire to broaden their impact in helping their clients stay healthy at home and avoid hospitalizations.

In Her Own Words, the  Role of a Care Transitions Nurse

Click Here for the orignal article


What exactly is a transition nurse?

I work with a team of nurses and social workers that help prevent our patients from going into the hospital, as well as assist with the transition to and from different care settings (hospital, skilled nursing facilities, and back home).

What was your last job?

I was a team member on Portland Providence Medical Center’s Cardiac Telemetry Unit.

Tell us what an average workday looks like.

The transition team meets in the morning and we discuss which of our primary care patients are in the hospital, who needs a follow-up visit and what their discharge plan involves.

We also look at who recently went home and who might need a phone contact or a nurse to visit. Are any urgent visits coming up? Those are visits where a primary care provider (PCP) has asked the transition team to check in on a patient because either they, a family member or caregiver are concerned about a patient’s failing health.

We prioritize our day and assign the calls and visits. I typically see about three patients a day because they may be spread across the whole Portland metro area.

How do you find out about who needs to be seen? How does the information flow to you?

Ideally, our caregivers or family members would call the office and let one of our carecoordinators know that a patient isn’t doing well and that they are either considering sending the patient to the hospital or have already done so. Sometimes they are unsure what course to take and the care coordinator will contact the patient’s PCP so that they have an opportunity to respond to the caregiver’s concerns and possibly prevent an emergency room trip.

If the PCP believes that an in-person visit is important but isn’t able to see the patient, they may request that a nurse goes out and then we communicate back our findings. We are also notified every day by the area hospitals if a patient of ours was seen in the ER or was admitted. Every patient gets a phone call after discharge, and if the conversation is sounding like they need to be seen, and the PCP is unavailable, we will go out to do the follow-up visit.

How do you see your job fulfilling the mission of Housecall Providers?

We are able to really meet patients where they are and support them so they can stay in the home and out of the hospital because most of them do not want to go there. A lot can be lost in translation when a patient goes to the hospital or nursing facility and back home again. We make their transitions that much easier.

What is your favorite part about working here?

I like that it’s a smaller group of people and you really get to know who you work with every day. Even though we are not a large medical provider, we have a huge impact on the community and are a leader in managing transitions and providing health careat home.

What do you love about Portland?

I like being close to everything; we have the mountains and ocean, rural and urban areas and its pretty much got everything you could want. It’s a fun, quirky place to live!


On a related note, one of Ankota's recent care transitions whitepapers, entitled "Selling Care Transition Services to Hospitals" is available for download and we think you'll find it useful.  Please click the link or the picture below to download.  If you're interested in scheduling an online demo of our home care or care transitions software solutions, just click this button:

Click Here for a Free Demo


Ankota provides software to improve the delivery of care outside the hospital, focusing on efficiency and care coordination. Ankota's primary focus is on Care Transitions for Readmission avoidance and on management of Private Duty non-medical home care. To learn more, please visit www.ankota.com or contact us.




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