Did you know that some of the industry’s most talented and caring registered nurses are at DCI? Our nursing staff has helped DCI achieve the lowest mortality and hospitalization rates among large dialysis providers for the past 13 years in a row. We think our Nurses are pretty awesome; they make a difference in our patients' lives by helping them live longer and achieve a better quality of life.
Our mission is “the care of the patient is our reason for existence.” What’s yours?
For DCI ESRD patients, the Care Coordinator (RN or LPN) provides in-hospital, in-center and/or home coordination of care for the chronically ill, high-risk older adults hospitalized for common medical and surgical conditions. In addition, the CC focuses on helping the patient and family caregivers develop the knowledge, skills and resources essential to prevent future decline and re-hospitalization. This CC will pay special attention to the patients desiring transplant, and help to coordinate the system through education, transplant referrals, coordinating appointments and following up with the patient and the family as needed.
- As the primary coordinator of care, the ESCO Care Coordinator will assist with continuity throughout the entire episode of care
- Help patients manage health issues, prevent decline and identify new risk factors
- Work with DCI Pharmacist on medication reconciliation and management
- Communicate with primary physician/nephrologist that his/her patient has been admitted to the hospital or desires transplant
- Daily monitoring of hospital admissions for patients at assigned clinic(s)
- Visit assigned patient who is admitted to hospital within 1 business day to review chart
- Prior to hospital discharge, confirm office visit with primary Nephrologist’s office has been scheduled
- Communicate order changes and discharge summary from the hospital to the dialysis clinic
- Visit patient in home or clinic post discharge from hospital
- Early identification of health risks to achieve long term positive outcomes and avoid events that lead to re-admissions
- Collaborate with local transplant professionals to create best practices for care coordination to improve transplant outcomes