Provides 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.
- Helping patients manage health issues, prevent decline and identify new risk factors.
- Medication reconciliation and management.
- Communicate with physician that his/her patient has been admitted to the hospital.
- Visit patient admitted to hospital within 24 hours to review chart.
- Confirm office visit with Nephrologist office within one week prior to discharge.
- Visit patient in home or clinic within 48 hours post discharge from hospital.
- In order for continuity of medical care between hospital and primary care physicians to be established, the TCC 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.A
- 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.
- Multidisciplinary approach that includes the patient, family and their caregivers.
- Communication/Transmission of order changes and discharge summary from the hospital to the dialysis clinic.
- Monitor hospital admissions daily at assigned clinic.
- Participates in discharge planning for all DCI patients associated with assigned clinic and works closely with hospital discharge team.
- Lead a weekly Interdisciplinary team meeting to focus on at risk patients including those who have just been discharged from the hospital or are at risk of being admitted to the hospital.
- Track outcomes and data comparison.