Danielle Duns Email & Phone Number

As a hospital care coordinator I work with patients who have services through Home and Community Care, or patients who will require services in order to be discharged from hospital safely. I work with the multidisciplinary teams throughout the hospital to ensure safe and appropriate discharges of patients who have been medically cleared for discharge, and help to provide seamless care coordination from hospital to home and beyond.

Our Transitions Program was created to focus on the transitional points in the patient’s life cycle of contact with the health care system. In partnership with Markham Stouffville Hospital, it harnesses manpower to work with the patient, MSH hospital intake and discharge planners, to serve the patient as comprehensively and effectively as possible to meet and exceed the patient’s needs, desires, and beliefs as they transition between the home and hospital as well as the hospital and home. This utilizes the entire family health team as referrals to IHPs are made when appropriate. The ultimate goal is to reduce hospital based care while affording the patient a better health care experience. The program is not specific to one population but rather touches on many- seniors, mental health patients, chronic disease patients, etc. The program follows up with every patient (via telephone or in person) who has visited or been admitted to hospital, regardless of diagnosis. It provides home visits for staple removals, 3 day well baby visits and assessments for pts unable to make it to the office. We collaborate with the hospital and outside sources such as the LHINs for shared care and care coordination and have overcome the challenges of privacy (from a hospital standpoint) through meetings and the use and benefit of technology. Our EMR pairs nicely with Markham Stouffville Hospital to provide us next-day access to medical records, consultation notes, diagnoses, lab work, medication changes, etc.

As part of the Diabetes Care Team I have a multi-faceted role. I facilitate and co-facilitate Diabetes Conversation Maps, group education sessions of up to 8 patients that focuse on one of 4 topics: How Diabetes Works, Diabetes Medication, Healthy Eating and Active Living and Diabetic Foot Care. These are interactive sessions that allow patients to share information from each other as well as learn new information from their facilitators without using a didactic approach.I also pair up with physicians to complete Diabetes Flow Sheets for our diabetic patients at their 3 and 6 month visits. This involves information gathering (height, weight, waist circumference, BP) and discussing the pt's diabetes with them. I look at their A1C, FBG, and other lab values including LDL, total/HDL ratio, ACR, eGFR, etc to detect areas of improvement. I also discuss psychosocial aspects of diabetes, ensure pts are up to date on their required Pneumovax and flu shots, and discuss yearly testing (foot exam, eye exam, POC machine calibration against venous draw, etc) when appropriate. If required I can make referrals to our pharmacist, diabetes educators, dietitians, OT or a DEC as a way to work with the patient in decreasing comorbidities and improving prognosis.

I oversee the anticoagulation education and management of patients on Coumadin. I take blood samples, interpret lab values, and adjust Coumadin dosing accordingly based on a Medical Directive to keep patients' INR within a therapeutic range.I am currently training to assist with the Medication Reconciliation program as well, for patients who have recently been hospitalized. This program allows us to sit down with our patients, discuss their hospitalization, and reconcile all medications they have had added, changed, or deleted from their regimen. It allows us to stay up-to-date on medications and labs while ensuring pt safety regarding dosing, interactions and contraindications.

My time is split between our Year Round Clinic (YRC) and our Annual Health Assessments (AHA). In MWC I engage in a variety of skills including ear syringing, vaccinations, allergy shots, B12 injections, testosterone injections, suture/staple removal, dressing changes, ECGs, BP Trus, and pelvic/breast exam assistance.In CHA I am responsible for the vaccination and cardiac risk factor station where I ensure patients are up to date on their vaccinations based on age, history and travel. I also discuss cardiac risk factors for Framingham Risk Score calculations and sometimes discuss mammograms and colonoscopies.

At MSH I was a float pool nurse; units I floated to included ED, ICU, In-Patient Surgical, Surgical Short Stay, Medical, Palliative, Rehab, and Admission Assessment Unit (AAU). I worked both day and night shifts and thus would have anywhere between 1-8 patients dependent on unit and shift. Throughout a shift I would be responsible for vitals, medication, interdisciplinary communication, dressing changes, bloodwork and/or IV insertion/maintenance, tests (x-ray, U/S, CT scan, etc), patient hygiene, carrying out new orders, and any other issues that may arise over the course of the 12 hours.My skill set and experience included IVs, phlebotomy, dressing changes, tube (NG, G, NJ) maintenance, medication, catheters, line (central, PICC, Port-A-Caths, ART) maintenance and dressing changes, drain (JP, Pigtail, Hemovac) maintenance and dressing changes, patient and family communication, ventilator monitoring and maintenance, suctioning, stomas, lab result interpretation, ECGs (6- and 12- lead), etc.

Bachelor'S Degree, Registered Nursing/Registered Nurse

Activities and Societies: President of Nursing Students Association of York (NSAY) Vice-President of Health and Wellness Club Member.

Bachelor'S Degree, Health Services/Allied Health/Health Sciences, General

Activities and Societies: President of Health Sciences Student Council Bachelor of Health Sciences (BHSc), Honours