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SFHCP Partners with Saint Joseph

Saint Francis Healthcare Partners Population Health department partners with the University of Saint Joseph School of Nursing, the Saint Francis Hospital and Medical Center’s Department for Nursing Education and the Hoffman Heart Outpatient Heart Failure Clinic, to reduce readmissions for high-risk patients.

Nursing student partners will work with an SFHCP Navigator and their USJ Clinical Advisor to complete a semester of a “community nursing rotation”. Students will meet with patients and families during their inpatient admission, collaborate with case management and unit nurses on the discharge plan and conduct up to four home visits within a thirty day period post-discharge. The home visits will include a nursing assessment, in-depth patient education and coordination of care with community partners.

The goal of this program is to engage the patients and families in the coordination of care across the continuum resulting in improved readmission rates, attendance at follow-up appointment, and improved patient experience.

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