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A healthcare provider sits at a counter in an exam room, speaking with a client who sits across from them.
Figure 30.1 A health care provider listens to the client to gather information to aid in care coordination. (credit: modification of work by Scott Housley/CDC, Public Domain)

Mrs. Johnson is a 72-year-old client with multiple chronic conditions, including diabetes, hypertension, and heart failure, living in a rural community. After a hospital stay during which she received appropriate medical interventions for exacerbation of heart failure and experienced symptom improvement, Mrs. Johnson has been discharged from the hospital and is going home. The nursing role in the transition from hospital to home is to ensure the client is safe and continues to receive the necessary care and support they need. Ensuring a smooth transition from hospital to home is critical in preventing readmissions and promoting the health and well-being of clients. Nurses play a central role in making this process as seamless as possible.

Transitions of care and care coordination are pivotal in the delivery of high-quality, client-centered care in the community. Transition of care refers to the movement of clients from one health care setting to another or from one level of care to another. Care coordination involves the deliberate organization and integration of health care services across different providers and settings to facilitate the delivery of holistic and continuous care to individuals and populations. As individuals move between health care settings or their care needs change, smooth transitions and effective coordination are essential for optimal health outcomes and client well-being.

This chapter aims to provide a comprehensive understanding of transitions of care and care coordination in community health nursing. By exploring the principles and best practices in transitions of care and care coordination, this chapter seeks to empower community health nurses in their roles as advocates, coordinators, and educators in the health care system. By mastering the art of transitions and coordination, community health nurses can positively impact the health outcomes and well-being of individuals, families, and communities they serve.


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