- Website URLhttp://www.wilsonmedical.com
- Phone Number252-399-8040
How We Improve Care Transitions
- Community Care Transitions Program – our nurse makes contact with patients in the hospital, provides follow-up with home visit after discharge, follows patient for 3 days and calls to check on patient.
- Patient can call nurse. LACE tool is used to identify patients at high-risk for admission – case management evaluation, and sets patients up with appropriate community resources.
- In current initial planning – handoff tool with skilled nursing facilities to hospital to improve communication and holistic care. Goal reduce readmissions from skilled nursing facilities. Baseline is at 51% of all readmissions are currently from skilled nursing facilities and Home Health Agencies.
- Next steps to implement with Home Health Agencies.
- Local Skilled Nursing Facilities
- Community Care Transitions Program
- Home Health Agencies
- Long-term Acute Care Hospitals
- Local Federally Qualified Health Center
- State Agencies – Behavioral Health
How We Measure Our Efforts
- Reduction in Readmission Rates
- HCAHPS Transitional Care Survey Results
- Readmission Rates
- Address1705 Tarboro Street SW, Wilson, NC 27893
- Primary Contact NameCortney Kulers and Rhonda Leegins
- Primary Contact Emailcortney.email@example.com and firstname.lastname@example.org
- Primary Contact Phone252-399-6157 and 252-236-5826