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?
The Dialysis Nurse-Dialysis Care Coordinator (DCC) will provide comprehensive in–hospital planning, in-center and home follow-up for the chronically ill, high-risk older adults hospitalized for common medical and surgical conditions. In addition, focus is given to helping the patient and family caregivers develop the knowledge, skills and resources essential to prevent future decline and re-hospitalization. Responsible for covering patients admitted to the Hospital Systems.
- The Dialysis Care Coordinator will assist with continuity throughout the entire range of care.
- Helping patients manage health issues, prevent decline and identify new risk factors.
- Communicate with physician that his/her patient has been admitted to the hospital.
- Monitor hospital admissions daily at assigned clinic.
- Visit patient admitted to hospital within 24 hours to review chart.
- In order for continuity of medical care between hospital and primary care physicians to be established, the DCC will accompany patients to first follow-up visits.
- Comprehensive, holistic focus on each patient’s needs including the reason for the primary hospitalization as well as other complicating or coexisting events.
- Active engagement of patients, their family and informal caregivers including education and support during and after hospital admission.
- Emphasis on early identification and response to health care risks and symptoms to achieve long term positive outcomes and avoid adverse and problematic events that lead to re-admissions.
- Communication/Transmission of order changes and discharge summary from the hospital to the dialysis clinic.
- Builds alliances with hospitals and other providers of care to renal patients
- Follows and coordinates care of the patient as he/she approaches the need for renal replacement through the first 90 days of renal replacement.
- Provide patient education throughout the hospital stay, including but not limited to, access care, limiting infection risks, fluid control.
- Coordinates education with dietitian and social worker to address dietary, emotional, adjustment, financial issues, insurance issues, employment issues, and other psycho-social needs.
- Coordinates vascular access placement if vascular or peritoneal access does not already exist.
- Medication compliance. The discharge medications will be reviewed with the nephrologists to ensure accuracy, with the patient to ensure understanding. The DCI Pharmacist will be available to assist with patient understanding and to apply for patient assistance programs if financial issues exist.
- Scheduling appointments with physicians, testing, other services, confirming the patient knows where to be, who to see, and has the means to get there
- Phone or home follow-up with new patients within 24-48 hours of discharge and at least weekly through the initial12 weeks of treatment. Each discharge plan is customized to the individual patient and identifies the resources and level of change that patients and their caregivers are willing to accept and execute.