Care Coordination for Care Improvement Initiative

What Is It?

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.

Satisfied SOS Patients

Just a note of grateful thanks for the arm and hand surgery performed on my brother, John S. What a wonderful positive change you made in his life. Your patience, kindness and sincere way of treating John is much appreciated by his whole family.  We will always be thankful for your skill and expertise. You bring a passion and love of work work that is rarely seen today. We thank you for that.

Leo S.

© 2018 Syracuse Orthopedic Specialists