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Ask the Doctor: Mary Free Bed's Spinal Cord Injury Nurse Care Coordinator

By Sam Ho, MD, Spinal Cord Injury Program Medical Director

I know you wonder when, or even if, you should call with a medical question about your spinal cord injury care. If you have questions, I encourage you to “ask the nurse,” Amy Arends.

Most of you are familiar with Amy through our Spinal Cord Injury Clinic. But Amy has an expanded role as our nurse care coordinator for the Spinal Cord Injury Program. This means Amy coordinates service delivery for our Spinal Cord Injury Program patients on a life-long basis, beginning at any point of entry into the Mary Free Bed Spinal Cord Injury Program system of care. Amy’s specific duties include:

Giving input into patients’ inpatient spinal cord injury education and developing and providing the outpatient educational plans.

Amy works closely with the spinal cord injury inpatient nurses. If, for example, there are any concerns that the nurses have regarding an inpatient’s ongoing care needs, they alert Amy so she can follow up with specific patients and monitor how things are going for them after discharge.

Monitoring discharge from inpatient to outpatient services, as well as other service transition points.

Amy often attends inpatient and outpatient team conferences so she can be aware of what's going on with each patient and closely monitor their care needs and progress.

Serving as an internal case manager by coordinating services and advising patients throughout their life-long course of care at Mary Free Bed.

Amy touches base with the spinal cord injury inpatients before discharge. She encourages patients to call her with questions or if they need assistance after discharge. Amy also routinely calls patients within the first several days after discharge from the inpatient program to see if things are going smoothly.

Providing patients and families with information and referral assistance.

Amy works closely with all members of the Spinal Cord Injury Program, including all of the spinal cord injury physicians. If she can't answer a question herself, she ensures that patients are referred to another team member or resource person.

Collaborating with insurance case managers and other external service providers.

Amy makes certain that key people involved in our patients’ care get the information they require to provide needed services.

Serving as a resource for patients, families, team members, and community.

Amy also screens new patients who are referred to our spinal cord injury physicians through the Spinal Cord Injury Clinic. Her clinical duties include:

  • Preparing charts before a patient is seen by one of our doctors
  • Completing a preliminary screen of the patient’s level of functioning and communicating these findings to the physician and other team members who may assess the patient (PT, OT, social work, etc.)
  • Obtaining and communicating any lab test results such as X-rays and MRI’s
  • Arranging medication, lab work, medical evaluations, or other orders prescribed by our doctors
  • Coordinating referrals for therapy, social work, or other community resources
  • Answering calls or other inquiries from patients, evaluating problems, and developing care plans
  • Overseeing the Spasticity Clinic
  • Assisting with baclofen pump refills

Contact Amy, Spinal Cord Injury Nurse Care Coordinator

616.242.9216 or 800.528.8989

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