Abstract
One out of five Medicare beneficiaries is readmitted within 30 days after hospital discharge, and as many as three in four readmissions are preventable. This study describes transitional care interventions (TCIs) delivered by one faith community nurse (FCN) to at-risk seniors living in a certain ZIP code. Two years of nursing documentation (2,280 interventions) were translated into Nursing Interventions Classification standardized nursing language. Results indicate the FCN provided priority TCIs including spiritual care. In fully describing TCIs using a nursing language, results support that the FCN transitional care model is a method worth exploring to provide wholistic transitional care.
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