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The Transition Management Model was developed by and for nurse care coordinators at an Independent Health Network to reduce Medicare and Medicaid 30-day readmission rates. Preimplementation assessment revealed the need for a nursing science framework to effectively reduce 30-day readmissions. The model was developed through thoughtful integration of transitions theory with best practice guidelines set forth by Project BOOST. Initial results of the Transition Management Model produced a decline in readmission rates by 11%. The Transition Management Model initiative can serve as an exemplar for the integration of transitions theory to best practice guidelines to effectively reduce 30-day readmissions.
