Perfect partnership

From left, Morristown Medical center nurse manager, Patricia Primmer; Trish O’Keefe, MMC director of nursing and acute care services; and Brandee Fetherman, MMC nurse manager.

Exceptional Parent magazine published an article in its March issue about Matheny’s transition nursing care program—the assignment of a full-time transition nurse who accompanies our patients to acute care hospitals and is available for consultation with the hospital’s staff. Our partner in this project is Morristown Medical Center, and the article focused on the spirit of cooperation that exists between the two institutions.

Pointing out that Matheny has “a very complex patient population,” Morristown nurse manager Patricia Primmer, RN, said having “someone who can educate the staff on what care is needed is very important.” Added MMC nurse manager Brandee Fetherman, RN: “Some of our staff have never seen people with these conditions before. The apparent behavior that is observed may be totally different from what the behavior truly is.” Morristown’s physicians and residents “have learned from this model,” said Trish O’Keefe, RN, MMC’s director of nursing and acute care services. The average length of stay for Matheny patients at Morristown, she added, used to be longer, but “because of the transition program, they’re now often able to return to Matheny sooner.”

Jeanne Lavelle, RN, Matheny’s transition care nurse for hospitals, said one reason the program is working so well is that “everything started at the top with Trish’s support and trickled down. Whenever we had our initial meetings, they were fully attended by the nurse managers. I see them all the time; they know who I am. I have my Morristown ID, and sometimes I have participated in rounds.”

What transition nurses do

Jean Lavelle, RN, Matheny’s transition nurse, center, confers with Lisa McKenna, RN, left, and Dr. Surbparkash Singh, staff physician.

Matheny’s transition nurse program is designed to assist our patients requiring services in other medical settings, both inpatient and outpatient. They understand the needs of our medically fragile patients and make daily visits to acute care settings to provide vital patient-specific information. The result: a smooth transition into and out of these settings, including all ambulatory care visits, too.

The goals of transition nursing are:

• Reduced hospital readmissions within 30 days.

• Increased patient, family and caregiver satisfaction.

• Accurate medication reconciliation.

• Improved communication across healthcare settings.