Care Management

Give Your Complex Patients the Support They Deserve

The DukeWELL™ Complex Care Management program supports eligible, high-risk patients with a variety of interventions proven to reduce avoidable readmissions and ED visits, improve medication adherence, and reduce appointment no-show rates.

Expand each of our services below to learn about DukeWELL™ complex care management interventions and what the evidence says about their impact on healthcare outcomes.

WHAT IS IT?

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.

MEASURABLE IMPACT

WHAT IS IT?

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.

MEASURABLE IMPACT

WHAT IS IT?

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).

MEASURABLE IMPACT

WHAT IS IT?

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.

MEASURABLE IMPACT

WHAT IS IT?

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.

MEASURABLE IMPACT

WHAT IS IT?

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. 

MEASURABLE IMPACT

WHAT IS IT?

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.

MEASURABLE IMPACT

WHAT IS IT?

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.

MEASURABLE IMPACT

WHAT IS IT?

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.

MEASURABLE IMPACT

WHAT IS IT?

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.

MEASURABLE IMPACT

WHAT IS IT?

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.

MEASURABLE IMPACT

WHAT IS IT?

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

MEASURABLE IMPACT

WHAT IS IT?

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.

MEASURABLE IMPACT