PINEHURST – Home health patient care coordinator Darnell Marks has taken a new role with FirstHealth of the Carolinas with the newly established position of heart failure transitions nurse. The position was created through a two-year grant funded by The Duke Endowment to improve care coordination for patients with heart failure.
Marks is based at FirstHealth Moore Regional Hospital, where she works directly with all of the hospital’s heart failure patients. Her role includes patient education, referral to appropriate resources, and oversight of transitions and follow-up to improve the quality of care for patients and their families.
“I take every preventable hospitalization of heart failure patients personally,” Marks says of her new role. “I don’t believe patients have to go back into the hospital nearly as often as they do. There is a gap in the care of these patients, and that is education and teaching to self-manage. I want to fill that gap. I want to be able to help patients understand their condition and help them find self-motivation to make the changes they need to prevent being hospitalized. This will lead to better quality of life and will empower patients in their own care.”
The innovative program is the most recent development in the creation of FirstHealth Care Transitions Services. Under the leadership of Patty Upham, Care Transition Services includes home health nursing and therapy services for patients who qualify; care management for patients who do not qualify for home health but who require in-home education and ongoing monitoring; and care transitions nurses (specially trained nurses embedded in different care settings who are key resources for patients as they move across care settings).
“Patients with chronic disease move frequently and often ineffectively across care settings,” Upham says. “This is particularly difficult when these complex patients move from the hospital to home. Our Care Transition nurses coordinate care and improve communication across care settings to improve patient outcomes.”
The program’s goals are to reduce unnecessary hospitalizations and emergent care use, and to improve the quality of life for patients suffering from heart failure.