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The Sleepy Eye Herald Dispatch - Sleepy Eye, MN
  • SEMC develops Transitional Care Management program

  • In an effort to reduce costly hospital readmissions and to keep patients at home in their own beds, Sleepy Eye Medical Center (SEMC) has developed Transitional Care Management (TCM).
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  • In an effort to reduce costly hospital readmissions and to keep patients at home in their own beds, Sleepy Eye Medical Center (SEMC) has developed Transitional Care Management (TCM).
     
    TCM assist individuals in maintaining his or her prescribed health regimens and improve patient care and outcomes as he or she transitions from hospital to home.
    TCM provides assistance with a safe transition home for patients hospitalized with diabetes, congestive heart failure, chronic obstructive pulmonary disease and other chronic illnesses. It fills an important gap in healthcare delivery as they navigate through the healthcare system.
     
    Wendy Borth, RN, BSN, CHPN is the manager for SEMC TCM program and helps facilitate access to other community services and chronic case management based on the needs of the patient and his or her care giver. “I collaborate with physicians and other members of the healthcare team to streamline the plan of care based on goals identified by the patient.”
     
    The Transitional Care Manager guides the patient in the following areas:
     
    • Medication review for accuracy and education
    • Education about the illness to support improved self-management
    • Identification of early warning signs and when to call a doctor
    • Identifying and linking with community resources
     
    “TCM is a 30-day program where the TCM nurse visits the patient in the hospital on the day of discharge, follows up with a phone call in two working days, has a face-to-face visit with the patient’s physician and makes weekly phone calls to answer questions and assist with referrals as needed,” said Borth.
     
    For more information about TCM contact Wendy Borth at 507-794-8436.
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