What is Duke TeleHOPE?

Duke TeleHOPE (Health Optimization Program for Elders) is a weekly post-discharge telehealth video conference with local skilled nursing facilities (SNFs). TeleHOPE facilitates a multidisciplinary review of patients hospitalized at either Duke University Hospital or Duke Regional Hospital and recently discharged to one of our partner SNFs between hospital-based and SNF provider teams. These conferences allow for a brief discussion of each patient, focusing on key transitional care pillars. 

With support from DIHI (Duke Institute for Health Innovation), we have developed and implemented our pilot project—Use of telehealth video conferencing to improve the hospital-to-SNF care transition—which launched in July 2019. Our work has demonstrated the feasibility of telehealth video conferencing to improve the hospital-to-SNF transition and its benefit in both harm and cost reduction. This program is now sustained by the Duke Population Health Management Office (PHMO) as part of PHMO’s strategy to utilize existing continuing care relationships to enhance quality of care, communication, and data exchange across the care continuum.

Meet our Team

Why use telehealth for transitional care?
The hospital-to-SNF transition is complex and error-prone. Medically-complex patients discharged from hospitals to SNFs are at high risk for unintentional errors, rehospitalizations, and mortality.1  Poor communication of critical information during the transition to a SNF is a commonly cited reason for preventable readmissions.6  Limited access to hospital medical records by SNF clinical staff increases the risk for rehospitalizations, errors, and delays in care.7  Other preventable factors for SNF rehospitalizations include diagnostic and therapeutic complications, availability of onsite clinicians, and lack of advanced care planning prior to discharge.5, 10  

Telehealth video conferencing represents an efficient use of clinical expertise to build relationships with SNF-based clinicians, improve care for individual patients, and identify systemic problems that need collaborative interventions to bring improvement.

Overarching goals for include:

  • Patient harm reduction
  • Readmission reduction
  • Transitional care improvement
  • Identification of opportunities for health system improvements
  • Improvement in patient connection to existing health system resources

Who participates on the telehealth conferences?
Our Duke Health multidisciplinary care team consists of hospitalists, geriatrics nurse practitioners, and clinical pharmacists.

The participants from the SNF care team can vary by location, but they typically consist of a clinician, a nurse familiar with the patient’s care, an administrator, and any staff involved in the discharge process, such as a social worker or nurse navigator.

What is discussed during the conference?

  • Interval Clinical Update
  • In-depth medication reconciliation
  • Follow up studies 
  • Anticipatory guidance
  • Advanced care planning
  • Follow-up appointments
  • Emphasis on DukeWELL referrals

What SNFs participate in the TeleHOPE program?
Our current participating SNFs are:

Peak Resources Brookshire
300 Meadowlands Dr; Hillsborough, NC 27278
(919) 644-6714

Croasdaile Village
2600 Croasdaile Farm Pkwy; Durham, NC 27705
(919) 384-2304

Pettigrew Rehabilitation Center
1515 West Pettigrew St; Durham, NC 27705
(919) 286-0751

How do I get more information?
To learn more about how telehealth has improved hospital-to-SNF transtions of care, watch Dr. Aubrey Jolly Graham’s presentation here. 



If you are interested in participating in TeleHOPE please email DukeSNF@duke.edu.