November 2013

NCH's Liaison in Nursing Care Transitions program: LINCT

NCH's Liaison in Nursing Care Transitions program, also known as LINCT, is a nurse-driven organizational partnership with local skilled nursing facilities to ensure continuity of quality outcomes for older adult patients as they transition between the hospital and extended care continuum.

Over the past year and a half, NCH has formed a LINCT partnership with the Lutheran Home, Manor Care of AH, and Church Creek to improve patient satisfaction, expedite recovery time, and prevent unnecessary readmissions to the hospital. NCH has seen close to a 50-percent reduction in 30-day readmission rates at one of the facilities.

There are currently two LINCT nurses who serve as Geriatric Clinical Navigators across the continuum of care. Melissa Rafalko, RN, BSN-BC, and Cora Villaverde, RN, BSN, connect with hospitalized patients who are preparing for a transition to a partnering LINCT facility. Within 24 to 72 hours after hospital discharge, the LINCT nurses schedule a visit to see the patient in their new environment, ensuring continuity of planned services, treatments, and medications for a successful transition back to the community.

NCH is determined to provide exceptional care to our community, recognizing that patients' needs extend well beyond a hospital stay and well beyond the walls of our campus after discharge. With the expertise and support of an extraordinary inter-professional team, including the LINCT nurses, partnering skilled facilities, NCH Home Care, and Midwest Palliative Care, we join hands to ensure a successful transition for our most vulnerable patients.

For questions about the LINCT program, please contact Dina Lipowich, RN, MSN, NEA-BC, Director of Medical Nursing and Geriatric Services.