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New transitional care nurse roles filled at BCHA

Barbour County, W.Va. — Barbour Community Health Association is proud to announce Dannielle Summerfield, LPN and Margie Burner, RN to serve in their new roles of transitional care nurse at Philippi’s Myers Clinic and the Belington Medical Clinic.

Burner will fill the role as transitional care nurse at the Myers Clinic while Summerfield will work directly with patients at the Belington Medical Clinic.

These new positions of transitional care nurse at both facilities is exciting for both BCHA and patients as it will assist in improving patient outcomes and reduce readmissions.

Burner and Summerfield’s goals will include identifying patient goals, developing individualized care plans with the patient and team, and providing continuity of care throughout settings. Overall, transitional care nurses focus on closing the gap between the time of a hospital stay and the next follow-up appointment.

With roughly 20 patients, transitional care nurses will follow up with patients through in-person visits and phone contacts. The nurses also hold discussions with other team members, such as the provider, ancillary therapy, and the family.

Transitional care nurses will work closely with patients who have had two or more hospitalizations within six-months, insufficient social support, poor health literacy, or difficulty with compliance.

“I think it will be a great change for our patients at Belington Clinic because the amount of time between hospital discharge and their follow up appointment is essential. We need to make sure they have all the supplies and medications they need. I think I will succeed in this position because of the experience I gained working within the hospital system,” said Summerfield. “I will be reviewing the medication list and discharge instructions given to them when they leave the hospital to ensure we have the most accurate information we will need at their follow up appointment and assist them in scheduling follow up appointments with the appropriate providers and having proper supplies and medications called in.”

“A lot of times, patients do not understand what all changes have been made during that hospitalization and it is important for us to touch base with them and educate them about those changes so they can avoid re-hospitalization and remain as healthy as possible,” explained Burner.

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