JSN Dean Publishes Personal Narrative Highlighting the Need for Patient-Centered Care Coordination and Transitional Care

Beth Ann Swan, PhD, CRNP, FAAN, Dean of Jefferson School of Nursing at Thomas Jefferson University, is published in the “Narrative Matters” section of the November 2012 issue of Health Affairs. Swan writes of her experience after her husband suffered a brain stem stroke while he was in another city. Her narrative describes challenges that could have been minimized if accountable care organizations focused on patient-centered care were more prevalent.
As she tells her story, Swan highlights gaps such as lack of communication during her husband’s transfer from a hospital in one city to a rehabilitation center in another; difficulty acquiring complete copies of health records; and struggle in scheduling appointments with specialists in a prescribed time frame.
She notes that the lack of transitional care was a challenge even for her, a registered nurse with numerous professional connections. “After he was discharged, we were on our own…. No one was knowledgeable about Eric’s comprehensive care plan, and no one had or provided expertise in coordinating his still-complicated care once he was home.” Several transitional care models exist, but none are widely used, Swan says, although she suggests that the Affordable Care Act’s emphasis on forming accountable care organizations may change that.
“The bottom line: We need patient care and transition systems inside and outside of hospitals that work efficiently,” Swan says. “Until they do, patients run the risk of falling into a terrible abyss of uncertainty as they go out the hospital door.”
Read Swan’s narrative here.
Read other media coverage of her story:

For more information, contact Jane Clinton, 215-503-9865, jane.clinton@jefferson.edu.

Published: 12-06-2012

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