A DukeWELL team member provides your high-risk, in-need patient with appointment reminders, pre-appointment counseling and assistance with transportation to their appointment (if applicable). Co-pay assistance available for qualifying patients who have recently visited the ED and need to follow-up with a PCP.
A DukeWELL team member provides your high-risk, in-need patient with education on programs that pay for healthcare, food, low-income energy assistance, and more.
A DukeWELL team member assesses your high-risk, in-need patient’s proficiency at activities of daily living (ADLs), coordinates dental and PT appointments and secures durable medical equipment (DME).
A DukeWELL team member assesses your high-risk patient who is visiting the ED frequently and identifies opportunities to educate them about appropriate use of the ED or to enroll them in care management services.
A DukeWELL team member visits the home of your high-risk, in-need patient and conducts a clinical assessment, adjusting treatment as necessary. Your patient is connected to community resources and their home environment is examined for safety concerns.
A DukeWELL team member visits your high-risk, in-need patient in the hospital and reviews their transition plan (to SNF or home) and future condition management or palliative care needs. The team member enrolls your patient in a care management program and a DukeWELL nurse follows-up with the patient for a minimum of 30 days post-discharge.
A DukeWELL team member makes an in-clinic visit to your high-risk, in-need patient at time of their scheduled appointment to discuss possible care management opportunities.
A DukeWELL team member assists your homeless patient with short-term care and medical stabilization a) following hospitalization, b) following an outpatient procedure or c) while under medical treatment. Patient must be enrolled in LATCH.
A DukeWELL team member follows-up with your high-risk, in-need patient and their care team in the rehab setting or at home to ensure that discharge instructions are followed and medications are taken as prescribed.
A DukeWELL team member works with your senior patient undergoing certain elective and non-elective procedures to ensure optimal recovery after surgery. Procedures covered include total knee arthroplasty, total hip arthroplasty, lumbar and cervical spine procedures, CABG, and hip fractures.
A DukeWELL team member completes an initial health assessment (IHA) for your high-risk, in-need patient. The IHA contains questions about employment, income, access to services, physical environment, social supports and education. DukeWELL uses the results to help patients manage their chronic disease and connect patients to community resources so they improve their quality of life.
The DukeWELL team member provides intensive case management in order to help your patient complete successful disability applications. Disability applications are completed utilizing a national model called SSI/SSDI Outreach, Access and Recovery (SOAR). Patient must be enrolled in LATCH.
A DukeWELL nurse provides ongoing telephonic counseling to your high-risk, in-need patient who has diabetes, COPD, asthma, heart failure, hypertension, hyperlipidemia or ongoing mental health/substance abuse concerns. The nurse provides support with setting and accomplishing long-term, disease-specific health goals. Telephonic sessions include diet and exercise counseling, patient education, medication review and adherence discussions.