Nurse Navigator Case Study
I. Background
a. Explain your facility’s interest in pursuing the collaboration with Duke Health, including any previous experience with value-based arrangements or coordination with Duke Health (e.g., participation in Duke Health workgroups, relationships with Duke Health primary care or specialist physicians who see patients on site, work with Duke Health care coordinators). Pruitt Health Durham would like to pursue a collaboration with Duke Health in order to coordinate care of Duke Health patients effectively. Previously Pruitt Health Durham has collaborated with Duke Oncology Specialists to provide specialized care to oncology patients.
II. Managing Transitions
a. Explain in detail or provide copies …show more content…
Provide each patient with a follow-up phone call within 48 hours of discharge (please include whether or not this currently occurs, and how frequently); The Nurse Navigator provides follow-up calls to all residents within 48 hrs. of discharge. The Nurse Navigator reiterates the post discharge care plan and encourages patients and family to contact the DHS (Director of Nursing) or Nurse Navigator with concerns or any changes in condition that might warrant further medical attention or possible admit.
v. Transmit a SNF discharge summary to the patient’s assigned PCP (please include whether or not this currently occurs, and how frequently); At present, we do not provide a copy of the discharge summary for all patients’ PCP’s. We would commit to working with Duke PCP’s to implement this process. Our Nurse Navigators provide post discharge summaries to patients and families.
c. Please provide a current example (with names omitted) of your patient-centered discharge instructions regarding plan of care, medication list, etc. See attached example.
d. Describe whether and how Duke MedLink is currently used in your facility. Who has access? How often is it used? What are the purposes for which you use it the most? The Senior Nurse Navigator and Admissions Director have access to Duke MedLink and use it daily to manage the admission and discharges of patients.
III. Clinical
a. Explain your facility’s interest in pursuing the collaboration with Duke Health, including any previous experience with value-based arrangements or coordination with Duke Health (e.g., participation in Duke Health workgroups, relationships with Duke Health primary care or specialist physicians who see patients on site, work with Duke Health care coordinators). Pruitt Health Durham would like to pursue a collaboration with Duke Health in order to coordinate care of Duke Health patients effectively. Previously Pruitt Health Durham has collaborated with Duke Oncology Specialists to provide specialized care to oncology patients.
II. Managing Transitions
a. Explain in detail or provide copies …show more content…
Provide each patient with a follow-up phone call within 48 hours of discharge (please include whether or not this currently occurs, and how frequently); The Nurse Navigator provides follow-up calls to all residents within 48 hrs. of discharge. The Nurse Navigator reiterates the post discharge care plan and encourages patients and family to contact the DHS (Director of Nursing) or Nurse Navigator with concerns or any changes in condition that might warrant further medical attention or possible admit.
v. Transmit a SNF discharge summary to the patient’s assigned PCP (please include whether or not this currently occurs, and how frequently); At present, we do not provide a copy of the discharge summary for all patients’ PCP’s. We would commit to working with Duke PCP’s to implement this process. Our Nurse Navigators provide post discharge summaries to patients and families.
c. Please provide a current example (with names omitted) of your patient-centered discharge instructions regarding plan of care, medication list, etc. See attached example.
d. Describe whether and how Duke MedLink is currently used in your facility. Who has access? How often is it used? What are the purposes for which you use it the most? The Senior Nurse Navigator and Admissions Director have access to Duke MedLink and use it daily to manage the admission and discharges of patients.
III. Clinical