The Transition Team is a multidisciplinary team that addresses the healthcare needs of veterans receiving Inpatient Care, Outpatient Primary and Specialty Care, and Extended Care Services. The incumbent's primary functions are nursing case management and coordination of patient care. The incumbent provides nursing support to inpatient medicine and specialty teams, including assisting with discharges from outside hospitals. The incumbent provides nursing support to PACT teams, specialty clinics, and community-based outpatient clinics. Patients that require Transition Nurse intervention include, but are not limited to, nursing home patients, patients requiring home health/hospice services, and high-risk patients. High risk patients include those with
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