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  • 1.  ER Discharge Nurses in efforts to decrease readmission rates

    Posted 06-05-2025 10:54

    Hello all, 

    Does anyone know of, or manages a program made up of nurses whom reside in the ER to track a specific population of patients who get discharged from the ER in efforts to prevent readmissions/unnessary ER visits? 

    For example nurses dedicated to targeting cardiac patients whom continue to come to the ED rather than having established long-term care with a PCP and cardiologist etc. 

    Like a nurse navigator/transitional care nurse in the emergency rooms? 

    Please let me know if anyone knows or has done this type of initiative....

    Thank you. 



    ------------------------------
    Shannon Heiss
    Broward Health Nurse Connect
    Fort Lauderdale FL
    ------------------------------


  • 2.  RE: ER Discharge Nurses in efforts to decrease readmission rates

    Posted 06-06-2025 10:43

    Good Morning Shannon,

     

    No we don't have a program like that.  I work for an FQHC and there are several community clinics that contract with the area hospitals. While a navigation program could work inside the clinic (perhaps modifying the ECM division), I don't know how the multiple community clinics could collaborate on their individual ED abuse patients.

    It's a very interesting concept and I'm curious to read how others are working through this problem

     

    Lori J Roach RN, BCEN, BS, MHA
    Director, Nursing Services

    P 760-631-5000 Ext. 8004 F 760-414-3733
    Lori.J.Roach@vcc.org
    www.vcc.org

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  • 3.  RE: ER Discharge Nurses in efforts to decrease readmission rates

    Posted 06-07-2025 12:13
    My FQHC implemented a substance use disorder ED liaison nurse last year. He is employed by my organization, but spends about half of his time at the local hospital, mostly in the ED. We identified a gap in that patients would be seen in the ED and maybe get a first buprenorphine prescription, but then not get connected to regular care and end up back in the ED; a familiar story for many chronic diseases. With this new role, we hope to bridge the gap between the ED and our health center and support all paths to recovery. I haven't been too involved in the program, but would be happy to connect you with the nurse if you'd like to know more about his work and outcomes.

    -Charlotte



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