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Faith community nurse listening to a patient

Using the power of faith-based nurses to address the issue of Medicare readmissions.

Transitional Care

Chart illustrating that Transitional Care Services include safety checks, personal health records, medication reviews with PCP, watching for RED FLAGS, and emotional and spiritual support

In Whatcom County, like other counties across Western Washington, patients are leaving hospitals "quicker and sicker."


As many as 20 percent of rapidly discharged patients experience medical complications within hours or days that take them back to the hospital emergency room. Common post-discharge problems include inability to get help for basic needs, adverse medication reactions, infections, and worsening of chronic conditions.


To address these Medicare readmissions, Health Ministries Network is using the power of faith based nurses, and health ministers to advocate for those in our congregations to:

  • Help establish a safe healing environment that supplies basic needs

  • Encourage clients and caregivers with emotional and spiritual support

  • Promote use a Personal Health Record for tracking and documentation

  • Encourage follow-up contact with PCP to establish a proper medication regimen

  • Watch for the "red flags" of worsening condition

If we are successful, faith-based transitional care will become an established health practice in faith communities in Whatcom County and every congregate who needs one will have access to faith based nurse or health minister for a post discharge visit and follow-up calls once a week for one month.


Faith based transitional care is funded by grants from the PeaceHealth Community Fund and Chuckanut Health Foundation.

To learn more, contact Sarah Lane at or 360-788-6408.

FCN reviewing notes with another person

Online Tools

Faith-Based Transitional Care Checklist

Spiritual History Tool

Home Safety Checklist

Primary Care Provider Visit Checklist

My Medicine List

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