Aurora West Allis Medical Center, West Allis, 2020 Community Benefit

Care Transition Nurses Transition Responsibilities According to Community Need

Our NICHE-certified Care Transition Nurses work to ensure that adults receive care that promotes function, autonomy, and dignity. During 2019:
217 older adults received transition services.
116 were referred to the West Allis Fire Department Community Paramedic Program, which works in conjunction with our Transition of Care program to fill a gap for high-risk patients when they are discharged, helping them to safely resettle in their home environment. 
2 Stepping On sessions were held, with 24 individuals participating. The Stepping On program offers older people information, strategies, and exercises to reduce falls and increase self-confidence.
In 2020, the Care Transition nurses at our hospital and other Milwaukee County locations (18 in total) along with 15 additional redeployed nurses, joined efforts to support our community in a new way:
To help reduce burden on the frontlines in our local emergency departments, urgent care locations, and physician offices, this group of nurses:
Rapidly developed a COVID-19 virtual monitoring program.
Monitored discharged COVID-19 patients (confirmed and suspected) seen throughout our system for 14 to16 days to assess their clinical and home situation.
Educated patients on the most current information available using our COVID-19 Resource Center, the LiveWell app, and other tools.
This group of RNs remained connected with our highest risk chronically ill patients to educate them on COVID-19 and to ensure they could access their providers and other wellness resources virtually or by telephone so they could remain safe in their homes.