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PHI Helps Design “Transition Specialist” Program

By Emily Dieppa Colo (she/her) | June 10, 2019

Care transitions can be challenging, especially for people leaving the hospital as they begin their journey to wellness and independence. Often that journey requires a short stay at a post-acute rehabilitation facility for additional therapy. For many, the transition between the hospital, to post-acute care, and finally back to their communities is characterized by confusion and frustrating miscommunication.

Trinity Health Senior Communities, in partnership with PHI, has designed an advanced CNA role (“Transition Specialist”) to provide continuity and assurance during a person’s time before, during, and after their post-acute stay, with the goal of reducing hospital readmissions and improving resident satisfaction.

Trinity made a deliberate choice to internally promote experienced CNAs to Transition Specialists, creating a true opportunity for professional growth while demonstrating Trinity’s commitment and belief in their team. Advanced roles in direct care have been shown to increase job satisfaction, reduce turnover, improve care, and create cost efficiencies—all vital aspects of strengthening the direct care workforce.

This April, PHI delivered a seven-day education program to the first group of Transition Specialists. These specialists will work at two Trinity sites located in Southeast Michigan: Marycrest and Fraser Villa. The training focused on building the skills that Transition Specialists need to successfully create a person-centered experience for residents and their families.

Because Transition Specialists, like other CNAs, will be uniquely positioned to observe and report changes in their clients’ conditions, PHI’s training covered topics related to chronic diseases such as diabetes, Chronic Obstructive Pulmonary Disease, and Congestive Heart Failure, as well as PHI’s Coaching Approach® to Communication curriculum. Throughout the seven days, Transition Specialists were introduced to case studies that allowed for experiential learning and exploration. PHI will also work with Trinity over the next year to develop and deliver a series of “booster sessions” that respond to the unique experiences of Transition Specialists on the job.

This transition specialist program, which launched on April 17 of this year, is funded through 2020 by the Michigan Department of Health and Human Services. Trinity plans to refine the Transition Specialist model over the next year and use it as a springboard for expanding the advanced role to Trinity communities across the country.

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