News and Commentary Macy Faculty Scholar Deanna Reising on Transitional Care Training

Deanna Reising, PhD, RN, ACNS-BC, ANEF, of Indiana University School of Nursing, discusses her new program at the school’s Center for Interprofessional Health Education and Practice training medical and nursing students on care transitions.

What are you working on for your Scholar project?
At Indiana University we have the Center for Interprofessional Health Education and Practice, and for the past five years we have been pairing medical and nursing students to work in simulations and standardized patient scenarios. With my Macy award, I will launch a new program at the Center that will allow approximately 100 medical and nursing students to work together and serve as “navigator teams” for newly discharged patients at risk for hospital readmission.

How will you structure the program?
Teams of two or three students will work with hospital case managers and be assigned to patients who would have been handled by a transition nurse. The focus will be on people who have been recently readmitted to the hospital or determined to be at risk for readmission.

Our ultimate goal is to have the interprofessional teams see patients in the hospital before discharge and then conduct routine home visits to assess the transition. What they assess will be driven by the patient’s care plan. Students will look at whether the plan of care is being implemented successfully at home. One area of focus will be medication management, a huge issue in health care today.

What are your ultimate goals for this project?

With this project, I am working toward advancing the Institute for Healthcare Improvement’s (IHI) triple aim, and exposing students to role models who are experts in population health management and transitional care.

This is also all about answering the question: Did we save a life? Did we make a difference in the quality of care for our patient and his or her family?

Long term, I would like to see this model spread across the Indiana University Health System and see more of our students out in the field on the front lines of patient care.

Do you have anything else you’d like to share?

I am excited to be a part of the Macy Faculty Scholar Program. There are two significant advantages to being a Macy Scholar. One is the support and expertise of the mentors and staff associated with the program, and the second is time. I can now focus on advancing this program.

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