Misty Landor MBA, MSN, RN, CNS, ANP-C, CCCTM is the Director of  Patient Care Practice of Ambulatory Care Coordination for Emory Healthcare in Atlanta, Georgia, where she is responsible for oversight and management of a multidisciplinary care coordination team focused on vulnerable, complex patient populations. Ms. Landor is Chair of the Care Coordination and Transition Management Special Interest Group for the American Academy of Ambulatory Care Nursing (AAACN). Ms. Landor’s role was elevated as a nurse leader during the COVID-19 pandemic and called upon to help develop a transitional care model to help transition patients returning home post COVID-19 treatment. “Many patients are returning home with new comorbidities and post treatment complications such as cardiac, respiratory, and renal complications from emboli”, said Ms. Landor.

The transition model is based on forging a partnership between the hospital medicine and primary care providers and requires communication and collaboration to bridge the gap. It also requires a multilevel structure of support to ensure patients can self-manage their conditions. Care coordination bridges the gap and provides the structure required that is based on a solid foundation in advocacy, education, and support. Ms. Landor modified a tiered risk assessment tool for providers to include assessment of preconditions and social determinants of health. This provides a methodology for RN care coordinators to determine where the patient falls in the care continuum and the level of ambulatory care management required.

“The most challenging part of transitioning patients’ home is having primary care providers accept new patients without the ability to do a complete new patient physical exam. Many physicians are not comfortable establishing care virtually. Physicians are more closely partnering and relying upon nurses to assess and manage their patients. Nurse are thriving in this environment because they have the communication and clinical assessment skills to address the self-care needs of vulnerable populations”, said Ms. Sandor.

“We have been billing for transitional care which is demonstrating nursing’s value generating revenue for the organization,” said Ms. Landor. Ms. Landor has been conducting Webinars to educate providers on billing coding and the assessment tool.  In addition, Ms. Landor is educating providers about nurse’s role in care coordination and how they coordinate and collaborate with community partners and other disciplines to meet the social needs of patients. This model has been successful and is translatable to all populations and Ms. Landor hopes to push out across the Emory system. Ms. Landor is sharing her work with the greater nursing profession and has submitted to the Journal of Nursing Administration (JONA).