The Care Coordination for Care Improvement Initiative was developed to improve the quality of patient care while easing the transitions that happen before, during and after surgery. The initiative is designed to follow patients through their continuum of care, from surgical decision through 90-days after discharge. The goal is to improve the quality of patient care, improve outcomes, lower costs and ease transitions of care.
Who Participates in This Initiative?
Everyone involved in a patient’s care, surgery and rehabilitation, including:
- You, the patient
- Your Surgeon
- The Nurse Navigator
- Hospital/Discharge Planners
- Rehab providers
The Objective
A Nurse Navigator will work with you, the patient, for better care coordination through communication with you and/or your caregiver(s), by initiating and maintaining close contact before, during and after surgery to promote more efficient, high quality care.
The Desired Outcome
To create and implement an individualized care plan for each patient which leads to improved care, improved outcomes and greater patient satisfaction.
How It Works - The process begins when a patient and surgeon decide that surgery is necessary. A Nurse Navigator will be assigned to a patient’s case, and provide ongoing care coordination through the entire surgical episode to ensure that transitions of care between rehab providers is seamless.
Nurse Navigator Role
Our goal is to ensure high quality care is provided to promote recovery and return to normal daily living. Nurse Navigators will:
- Complete a comprehensive health and environmental assessment.
- Discuss discharge options and develop and individualized care plan with the patient and/or their caregiver(s). This will include the notification of appropriate post-op providers.
- Update the discharge plan as needed to ensure optimal recovery.
- Contact patient telephonically at specific intervals.
- Maintain a relationship with the patient for ongoing educational needs and to reinforce learning objectives.
Patient Role
You, the patient, are the most important member of this team. You will:
- Participate in all decisions about your treatment plan.
- Complete a pre-operative education class and Physical Therapy assessment.
- Ask questions.
Program Summary
SOS patients will be followed through their continuum of care, from the surgical decision through 90-days after hospital discharge. Their personal Nurse Navigator will maintain contact with them through all the phases. The Nurse Navigator will also continuously communicate with all the patient’s providers (hospital, home care, short term rehab, outpatient rehab) to continually assess and update the patient’s plan of care based on ongoing feedback from the multidisciplinary members of the care team.