Partners and Procedures Faith Community Nursing Aligns with New Trends in Healthcare Jan Erlenbaugh Gaddis, RN, Faith Community Nurse - BSN candidate Franciscan Health Karen Hardin, DNP, RN, NE-BC,CNE, Faith Community Nurse - Marian University Anita Siccardi, EdD, APRN,FNGNA, Faith Community Nurse - Dean Emeritus Marian University   Background Purpose of Initiative FCN Interventions Conclusion American Nurses Association (ANA) recognized FCN as a specialty nursing practice in 1998. ANA and Health Ministries Association (HMA) recently revised Scope and Standard of Practice: Faith Community Nursing (3rd ed.) to align with current healthcare trends. There is a plethora of literature on the need for hospitals and other healthcare organizations to evaluate and create new strategies to address community health issues. Church Health, Memphis, TN has developed a transitional care model with evidence based care for FCN. Franciscan Health has initiated a pilot program to expand continuity of care in the community setting. Indiana QSource Coordination of Care team provides support for this initiative. FCN bridge the gap in transitional care. The purpose is to create a model for collaboration between FCN providers and health care institutions across the state of Indiana. This project is to identify and assist healthcare consumers and family/caregivers who need additional resources in their home or community setting. This initiative will help distribute evidence of best practice among nurses. The benefits of collaboration with FCN’s will: improve quality of life increase overall satisfaction with healthcare engage self-care behaviors for the healthcare consumer Faith-based nurses are invited to walk the journey with healthcare consumers by providing hope and healing in a whole person approach.   Transition from hospital to home (Campbell, 2017) Preliminary Findings Partners and Procedures Fourteen patients referred in a six month period for follow-up to prevent hospital admission/readmission Primary medical diagnoses: COPD and cognitive impairment Primary nursing interventions: advance care planning, medication management Provide whole person care to include spiritual and social supports, build trusting relationship Identify caregiver support, health care representative, and/or power of attorney. Team support with ACO CM, FCN, NP and SW from palliative, PCP. Referrals to palliative care, CICOA and senior service, i.e. Meals on Wheels Expand continuity of care in the community setting Collaborative team approach with Accountable Care Organization (ACO), Palliative Care, and FCN at Franciscan Health Referral source ACO embedded RN physician practices Care coordinator RN referral to FCN Palliative care referrals Contact within 48 hours to schedule home visit Review and chart Electronic Medical Records (EMR) Referrals to community resources CMS – Indiana Qsource provides Coordination of Care team support Objectives References Recognize the potential impact Faith Community Nursing (FCN) has on patient-centered faith-based care. Discuss the collaborative role of Faith Community Nursing practice with health care providers to bridge the gap in transitional care. American Nurses Association and Health Ministries Association. (2017). Faith community nursing: Scope and standards of practice (3rd ed.). Silver Springs, MD: Nursebooks.org. Campbell, K. (2017). Transitional care training guide for faith community nurses. Memphis, TN: Church Health Center, Inc. Ziebarth, D. (2015). Factors that lead to hospital readmissions and interventions that reduce them: Moving toward a faith community nursing intervention. 1(1). International Journal of Faith Community of Faith Community Nursing. Retrieved from http://digitalcommons.wku.edu/ijfcn/vol1/iss1/1 Caring hands of heath care providers connecting with caring of faith community nurses for a healthier community