JOB SUMMARY: The RN Transitional Care Nurse is responsible for managing a patient’s successful transition from hospital to home and is accountable for developing, implementing, and evaluating comprehensive transitional care interventions for high risk medical and/or surgical patients at Candler County Hospital (CCH). He/she is responsible for managing the post-acute care of high-risk patients that are at risk for poor health outcomes, frequent emergency room visits, and hospital readmissions and working with complex and varied patients and situations.
Person in this position will identify hospitalized high-risk, complex patients for program enrollment and communicates with all entities involved in the care of the patient to promote and maximize care coordination. Key aspects of the Transitional Care Program protocols are based upon inpatient and post-discharge workflows. Inpatient workflow includes participation in hospital multidisciplinary daily rounds, patient and family education regarding disease states and self-care, identification of patient-level concerns regarding discharge, and anticipation of potential gaps in care. The inpatient encounters are designed to educate patients/caregivers surrounding their post discharge health care needs and to empower them to play an active and informed role in managing their care post-discharge.
ESSENTIAL FUNCTIONS of this job description include but are not limited to:
- Supporting the mission, vision, and core values of the organization
- Upon patient hospital discharge, the post-discharge workflow is telephonic follow-up for 30 days facilitating clinical care, patients access to appropriate services, and service referrals and appointments – this includes:
- a focus on medication reconciliation and adherence, management of patient’s quality of life and functionality, management of both acute and chronic disease states, identification and rectifying gaps in care, assessment and support of patient’s ability to perform self-cares, coordination of post-discharge appointments and services (durable medical equipment, home health), and coordination of care across the care continuum.
- Identifies patient/family education needs and ensures that patient/family members have adequate information to participate in transition planning
- Critically evaluates and analyzes physical and psychosocial assessment data
- Conducts health literacy assessment through the use of authorized system
- Interprets screening and selective laboratory/diagnostic tests
- Initiates and maintains communication and collaboration with physicians, social workers, care team leaders, staff nurses, other care giving disciplines, and patients/families to develop, implement, and evaluate a transition plan of care for each patient.
- Conducts a comprehensive patient/family assessment and transition/home care planning evaluation upon admission to initiate and maintain the patient's transition plan of care
- Utilizes financial and insurance resources as well as CCH assistance programs (i.e. Medical Assistance Program) to maximize the health care benefit to the patient
- Monitors the achievement of clinical outcomes and communicates with inpatient teams, primary and specialty
- Notifies physicians and staff, regional providers, and community resources (Home Health) regarding unanticipated variances
- Assesses complexity of care needs and potential/actual issues or gaps in care
- Arranges post-discharge medical and community referrals for patients with health problems requiring further evaluation and/or additional services
- Advocates for patients and families within the health care system with community providers and across the continuum of care
- Identifies, tracks, and conducts root cause analyses on 30-day readmissions to address programmatic and system-wide improvements
- Works with physicians, providers, and researchers to identify broader system issues affecting patient care
- Maintains current competency in nursing specialty by attending educational workshops; reviewing professional publications; establishing personal networks; participating in professional societies
- Functions as a contributing team member & communicates effectively with all levels of people.
- Promotes positive public relations to physicians, patients, visitors, other employees, and the community
- Participates in performance improvement activities
- Provides for patients’/significant others’ rights and safety; strives to manage situations in a manner to reduce risk while following legal and regulatory standards
- Performs other tasks and duties as assigned in an efficient, effective and cost conscious manner, complying with all hospital policies, procedures, and regulations
KNOWLEDGE, SKILLS, QUALIFICATION and EDUCATIONAL AND /OR EXPERIENCE REQUIREMENTS:
- Graduate of an accredited school of Nursing (RN Program)
- Current RN license, in good standing with the GA State licensing board
- Three (3) years of relevant clinical nursing experience - Equivalent combination of education and experience will be considered
- Basic Life Support (BLS) certification required
- Strong organizational and interpersonal skills
- Ability to:
- determine appropriate course of action in more complex situations
- work independently, exercise creativity, be attentive to detail, and maintain a positive attitude
- manage multiple and simultaneous responsibilities and to prioritize scheduling of work
- maintain confidentiality of all medical, financial, and legal information
- complete work assignments accurately and in a timely manner
- communicate effectively, both orally and in writing/electronically
- handle difficult situations involving patients, physicians, or others in a professional manner
- Provide excellent customer service skills and basic computer skills required
- Possesses good interpersonal skills, initiative, integrity, flexibility, adaptability, and must be a team player
PHYSICAL DEMANDS / WORKING CONDITIONS:
May be exposed to patient elements, prolonged, extensive or considerable standing/walking, sitting, bending/twisting, kneeling/squatting, reaching, climbing and should be able to lift 15 or more pounds using proper lifting techniques. Rapidly changing and stressful environment. Ability to communicate with various levels of people. Possible exposure to communicable and infectious disease and hazardous materials. Occasional exposure to unpleasant patient or unit elements (accidents, injuries and illness). Contact with patients under a wide variety of circumstances. Subject to varying and unpredictable situations. Handles emergency or crisis situations. Subject to many interruptions. Occasional pressure due to multiple tasks and inquiries.
The information in this job description is intended to describe the general nature and level of work being performed by people assigned to this classification and requirements for the performance of this job. They are not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified.
CCH is an equal opoortunity employer and drug free work place.