What Is Transitional Care?

Assisting patients in navigating the healthcare journey

By Kendra Gohl, Director of Nursing

Nursing excellence at Columbia Memorial Hospital in Astoria, Oregon

Kendra Gohl (right) with Vice President of Patient Care Services Trece Gurrad at the 2016 Nurse of the Year award ceremony. Kendra was named the 2016 Small Hospital Nurse of the Year by March of Dimes.

At the beginning of 2017 CMH’s Quality and Care Management departments embarked on the journey to initiate an organization-wide transitional care improvement project. Transitional care refers to the coordination and continuity of healthcare provided to a patient as they change locations or care providers.

All CMH caregivers provide transitional care as we assist patients moving from one care setting to another (e.g. hospital to home). But the social workers and nurses in Care Management coordinate most of these transitions for patients in cancer care, Hospice, inpatient, emergency, and clinic environments. They do this by providing nursing and social work support for patients who need emotional, behavioral, medical and resource assistance.

Our 2017 Successes

  1. Growth and expansion of the Cancer Collaborative social worker/transitional care role.
    Mari Montesano, MSW, serves as the Oncology Transitional Care Coordinator. She meets with patients and families and supporting their transition through the cancer journey.
  2. Integration of the Hospice social worker/transitional care role within Care Management.
    Mark Muse and Jeannette Johnson serve as the Hospice social workers. They meet with every patient and family, providing support, enhancing hospice services, facilitating bereavement programs.
  3. Implementation of transitional care for the Women’s Center and Pediatric clinics.
    In 2017 CMH received funding from Care Oregon to implement a Family Transitional Care Program. This program is focused on initiating adverse childhood event screening for pediatric and prenatal families. This screening allows us to identify families that have experienced trauma and support them as they move through the parenting journey.
    Misty Bottorff is our family transitional care coordinator. She has developed amazing community connections, implemented a consultation follow-up program for the Family Birthing Center and much much more!
  4. Growth of the inpatient care management team to allow us to assess each patient admitted to CMH.
    Our Inpatient Care mgmt. program is led by Margaret Santee, RN, Tonia White, RN, Kevin Levi, MSW, and Daniel Keesler, MSW.
    This amazing group assesses every patient admitted to the hospital to identify medical and social discharge needs.  They work with families, caregivers, community agencies and insurance companies. They serve as resources for emergency department referrals and this year have implemented a clinic referral program. Staff in any CMH clinic can make a referral to the Care Management staff.

What’s coming next?

In 2018, we expect to create a transitional care and integrative behavioral health program for Primary Care and will be placing a social worker in the Warrenton clinic.We are very exciting about the opportunities that his new program will bring to our primary care patients!