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  1. Fels, Jennifer MS, RN
  2. Allard, Billie Lynn MS, RN
  3. Coppin, Karen MSN, RN, CEN
  4. Hewson, Karen MSN, RN
  5. Richardson, Barbara MSN, RN-BC, CCRN


The shift in focus from individual episodes of illness to a focus on health and wellness, and population health, has created a need for care coordination to address the complex needs of high-risk patients as they transition through the healthcare continuum. A Vermont medical center identified the Clinical Nurse Specialist as having the requisite skills to fill the role of care coordinator. This article describes the development of the Transitional Care Nurse (TCN) program and includes case studies that exemplify how the TCN can intervene to improve care coordination.