Bridging the gap

With the aging population growing, nearly 20% of Medicare enrollees require a stay in a transitional care unit (TCU) every year.

Yet despite the fact that half of all nurses will work with older adults in some capacity, less than 1% hold specialized geriatric training.

A new initiative, led by Associate Professor Kristine Talley, PhD, RN, GNP-BC, FGSA, represents a strategic response to the looming national workforce need. Funded by a Health Resources and Services Administration (HRSA) grant, the School of Nursing created two clinical requirements: a five-week placement in a transitional care setting for Master of Nursing students and a three-week Continuum of Care Practicum for Bachelor of Science in Nursing (BSN) seniors. Together, they ensure that every pre-licensure graduate leaves with firsthand experience navigating the complex ecosystem of transitional care.

“All the stars aligned for this project,” says Talley, co-director of the Minnesota Northstar Geriatric Workforce Enhancement Program. “We realized we needed to move beyond basic bedside care and show students what a nurse actually does in these settings: leadership, system navigation and complex care coordination.”

The course is intentionally placed at the end of the BSN program, so students have the clinical foundation to see  the complexity of the systems.

“They aren’t there to perform basic care,” says Clinical Instructor Mary Ellenberger, DNP, RN, PHN. “They are there to follow a patient’s trajectory. What happened before they got here? Where are they going next? Where are the hiccups? What’s going well, what’s not going well? How do all the systemic factors interact with that?”

BSN students spend 24 hours immersed in the TCU. Each student is assigned a single patient and follows that person’s journey — reviewing charts, sitting in care conferences, and speaking with the patient directly about their concerns, hopes and fears.

Simultaneously, students rotate through experiences with social workers, infection preventionists, physical and occupational therapists, unit managers, and directors of nursing.

The guiding instruction in each session is to ask the professional how they have intersected with their patient’s care. Then go back and ask the patient how they experienced it.

For BSN senior Kendyl Sammons, the experience was a revelation. “There is so much that goes into transitional care and long-term care that I never would have considered,” Sammons says. “Actually talking with the head of social work and the nursing manager made me realize how much goes into this setting. It was a whole new appreciation for the sheer amount of effort that goes into creating a place where people can thrive and transition out of successfully.”

Developing systems awareness

Built around the 4Ms framework of Age-Friendly Health Systems — medications, mentation, mobility, and what matters — the course curriculum was developed by Talley, Clinical Associate Professor Laura Kirk, PhD, RN, and Clinical Associate Professor Mary Goering, PhD, RN-BC. It ensures that even students who never specialize in geriatrics leave the program with the clinical judgment and systems awareness to care for older adults anywhere in their careers.

Complimenting the clinical hours, there are 15 hours of didactic learning. One of the more eye-opening aspects of the course is its look at the financial architecture of health care. The curriculum dives into the reimbursement systems, insurance regulations and government funding streams that often determine where a patient goes — and whether they can go at all.

“Insurance is everywhere,” says Sahra Mohamed, a BSN senior. “In the hospital, we don’t really see insurance; it doesn’t seem to be part of our job. But in the TCU, we saw how Medicaid cuts or waiting for government funds could keep a patient from the home they want to go to. It opened my eyes to the financial side as a barrier to care.”

Ellenberger notes that when students witness a patient who has no Power of Attorney, no sufficient housing or sufficient food, the reaction goes beyond empathy.

“The students get indignant,” she says. “They want to do something about the laws and policies that perpetuate inequities and jeopardize the health of our communities. Once we zoom out from bedside care, the students want to fix the parts of the system that are failing people.”

Partnering with transitional care providers

The course’s success requires deep partnership with transitional care providers. At Ebenezer Integrated Care & Rehab (EICR), Director of Nursing Jen Sadiku, BSN, RN, PHN, was an early champion. When she heard about the concept, Sadiku saw an opportunity to offer something she herself had never received.

“When I went to nursing school and shadowed in a TCU, I was just shadowing the nurses,” Sadiku says. “I didn’t get a chance to talk to the interdisciplinary team or see what all that goes into caring for residents. When I heard the vision here, I thought this is a great opportunity and a unique situation for these students to see all of what goes into this work.”

Sadiku organized access across departments — therapy, social services, minimum data set coordinators, and her own nursing leadership office — so students could see the full operational picture. She makes a point of showing students what it means to direct an entire nursing department, from hiring to clinical oversight.

Michelle Schmidt, LSW, director of Social Services at the site, invites students into psychosocial assessments and rounds with the psychology provider, pulling back the curtain on care coordination from the social work perspective.

“I believe it’s our responsibility to work with students — to help educate and empower them,” Schmidt says, “because we need people like them.”

For Mohamed, the course shifted her perspective on where her career could go. “Before this, I didn’t know anything about TCUs. I thought it wasn’t the path I’d take,” she says. “But I really see myself doing education and infection control now. I like that TCUs are the bridge to help patients get to where they need to go. They are a place where patients can take their time.”