Department Spotlight: Transitional Care Coordinators
December 31, 2024
As a patient, your healthcare journey may seem overwhelming and confusing. Add a significant injury to the equation, and now you potentially have a rehabilitation detour on your road to recovery. Then you have to think about what happens next after you head home? In-home physical therapy? Home health? More rehab? There are many questions to answer about the next steps in your journey.
Enter: Renown Rehabilitation Hospital’s Transitional Care Coordinators (TCCs). As a rehab patient’s key support in the transition from hospital to home, this department ensures everyone on a patient's care team has the best information to deliver care after discharge while remaining in constant communication with the patient and family to meet their unique health needs.
At the Right Time, In the Right Place
The role of our Transitional Care Coordinators at our rehab hospital is exactly what it sounds like: helping patients transition from a hospital or rehabilitation setting back to their home or a lower level of care. Every step of the way, these experts are laser-focused on making sure patients continue to receive the support they need during this key transition period."The main goal of the Transitional Care Coordinator is to get the patient to the appropriate level of care at the right time and the right place,” said Marty Ackerman, Senior Transitional Care Coordinator. “Our day involves collaborating between the inpatient physiatry team, consulting team and attending team at the acute level, as well as the discharge planning team. We work with the patient’s family to come up with the best plan of care, whether it’s home health, inpatient, outpatient or acute care. Day to day, we see about 20-25 patients.”
Once a patient is released to go home after rehab, our Transitional Care Coordinators ensure each patient is properly set up with physical, speech and occupational therapy in an outpatient setting or at home. Working closely in tandem with the TCCs, the Discharge Planning Assistant sets up transportation, equipment and more.
“I start by listening in on our morning meeting to see who we might bring in, what the doctors say and what the rest of the team thinks in regard to seeing if a patient is appropriate for care at Renown Rehabilitation Hospital,” said Emma Van Patten, Discharge Planning Assistant. “I work closely with case management, so if any patient needs discharge equipment to safely get around, such as a wheelchair or a walker, I will order it from a durable medical equipment (DME) company or home health if the patient needs more assistance at their house when they leave. I set up transport for all the hospital admits and make sure everyone gets their equipment on time before they leave.”
The reach of the TCCs goes beyond hospital walls. In fact, their reach even goes beyond state lines and country borders. If a member of our community is injured and wants to come back to Reno for treatment, our TCCs will work with teams around the world to make that a reality.
"Recently I was able to help a member of our community, who was injured in California, come back to Reno and undergo rehab here,” said Sharon Trimmer, Transitional Care Coordinator. “It was a collaborative effort with the team that we got the referral from in California, working closely with insurance companies, working with doctors here, coordinating the transfer back from California – it was all especially rewarding. The patient was so grateful to be back home.”
"I love it when we work with these externals and get them back home,” added Marty Ackerman. “It is really quite an accomplishment. A patient can be in Europe, Asia, anywhere – we will help them. I was able to admit someone from Latvia by working with a global travel insurance company. We got medical records transcribed from Russian to English, and the patient’s family was very helpful with the translation.”
Thanks to the above-and-beyond efforts of the entire team at Renown Rehab and the best-in-class level of care they provide, our rehab hospital has been nationally recognized. And this award will certainly not be the end of the accolades the hospital collects.
"Becker's Hospital Review recently ranked Renown Rehabilitation Hospital as a top rehab facility in the state of Nevada and the U.S.,” said Marty Ackerman. “This was a very proud moment for us.”
“Every day is different. Each day we continue to experience new situations and challenges,” added Sharon Trimmer. “I appreciate the help of the team members who each bring unique perspectives and experiences to problem solve for the best outcomes. I love the opportunity to continue learning on daily basis.”
Our Transitional Care Coordinators would like to emphasize to readers that anyone is more than welcome to come to Renown Rehabilitation Hospital for a tour. They look forward to sharing what they do with our growing community.
Come Work With Us
Come Work With Us
The Trek to Transitional Care
Each professional on the Transitional Care Coordinator team brings a unique background and perspective to the group. For several, these roles are the culmination of years of hands-on patient care and experience – and many of our TCCs journeyed to this department after serving patients at Renown in another capacity.“I started as a case manager, and then I worked in a skilled nursing facility and was a floor nurse at Renown acute rehab. The nurses encouraged me to apply for the Transitional Care Coordinator position here, and I’m very happy with it,” said Cordell Jeakins, Transitional Care Coordinator.
“I worked with Renown Rehab while I was nursing for Renown Home Health,” added Kathi Kolodge, Transitional Care Coordinator. “I took a little break from nursing and when I returned, I was delighted to find this job.”
These different career paths inside and outside of Renown have provided our TCCs with valuable insights into the rehabilitation process and the challenges patients face when transitioning from the inpatient setting to the outpatient setting.
“I had clinical experience working as a bedside nurse, and when I decided to make the transition away from the bedside, I wanted to keep interacting with patients,” said Sharon Trimmer.
“I’ve been licensed since 1988 and have worked in neurology, med-surg, orthopedics, skilled nursing, staff nursing and case management, so I am fortunate to have an understanding of what post-acute care looks like,” added Marty Ackerman.
The team’s wealth of clinical experience allows them to navigate the complexities of post-acute care with confidence, from the direct patient care side to the administrative side, with a top goal in mind: improve patient outcomes
“I was previously a rehab therapy tech but got to see the hands-on work our team does and witness patients progressing,” said Emma Van Patten. “I wanted to expand my knowledge and see the administrative side.”
Our TCCs aren’t rookies – quite the opposite, actually. Between all of them, they hold years and years of experience in the field.
"We have all been doing this for quite a long time,” said Cordell Jeakins. “We have decades of experience between the five of us. For instance, I’ve been here 14 years, Sharon has been here 10 years and Marty has been here more than 20 years."
No challenge is too difficult for our TCCs, and they are challenges they embrace with everything within them.
New Year, Same Gratitude
As we approach the year 2025, our Transitional Care Coordinator team reflects on how thankful they are for how they all fiercely advocate for their patients’ needs. They all share that same mindset together.
“I just love how our team advocates for the patients,” said Kathi Kolodge. “Each one of us has had patients with complex diagnoses from a rehabilitation standpoint. Myself, along with my coworkers, have been the voice for our patients.”
This team’s gratitude also extends to their fellow coworkers. Not only are they advocates for their patients, but they also are advocates on behalf of each other.
“I love being a part of a team that works closely together and supports one another while having the opportunity to make a difference in patients' lives,” said Sharon Trimmer. “I call it, ‘wonderful serendipity.’”
“My coworkers keep me here at Renown,” added Kathi Kolodge. “I have made close personal connections with several of them. We all work well together and have each other's backs.”
It’s clear why our TCCs are so passionate about the work they do. So, why do they decide to bring those passions to Renown? Three main reasons came to light: working for a not-for-profit organization, providing a community service and recognizing our health system’s reputation.
“Renown is a great community nonprofit,” said Emma Van Patten. “It really feels like you’re helping people who deserve it. It feels very rewarding.”
“It’s important for me to work here and be a part of this team,” added Marty Ackerman. “We provide a great service to our community. That is what keeps me going.”
“I was born and raised here, and I always knew Renown had a great reputation,” added Cordell Jeakins. “This is a wonderful place to work. I feel very fortunate.”
It takes a village to give the level of care that our Transitional Care Coordinator team offers daily. As such, they have quite a few departments to thank for their dedication and collaboration:
- Consulting physician team
- Inpatient physiatry team
- Case management
- Transitional care navigators with Hometown Health and Senior Care Plus
Our Transitional Care Coordinators are a guiding force at Renown Rehab that empowers patients to take charge in their recovery journey. With their collective compassion and diverse expertise, they bridge the gap between hospital care and home.
“Coming to rehab for some can be a life-changing experience, especially at a time when they are confronting challenging conditions. We can get them through the door providing hope. The team here works like magic to help patients achieve amazing outcomes. We are committed to helping patients gain the opportunity to get their hope and independence back,” closes Sharon Trimmer.