Transitions of Care RN
5 days ago
POSITION SUMMARY:
The Transitions of Care Nurse Complex Care Manager works with relevant stakeholders to identify and engage patients in care management with a focus on enhancing patient health and well-being, increasing patient satisfaction, and reducing healthcare costs. The nurse works with inpatient, complex care management, and community-based staff to develop an individualized and patient-centered plan of care. Excellent interpersonal skills, clinical expertise in conditions prevalent in the complex care Medicaid population (Substance Use Disorder, Serious Mental Illness, Congestive Heart Failure [CHF], individuals experiencing homelessness, etc.), patient engagement skills, and the ability to work independently and collaboratively are key requirements of the job.
The nurse works at inpatient facilities and integrates with inpatient care operations – documenting in local medical records, participating in care planning efforts, etc. to ensure seamless care planning for patients while also serving as the link to continuing outpatient care. By complementing existing care teams on the inpatient and outpatient side, the nurse serves a critical role in connecting the dots across care providers and community agencies.
Main responsibilities will include assessing high-risk patients and understanding their post-discharge needs; collaborating with CCM teams to create and coordinate cohesive longitudinal care plans; participation in appropriate triage and prioritization of patients to post-discharge programs in alignment with longitudinal care plans; coordination of referrals to appropriate post-discharge programs; engagement in creative problem-solving around discharge planning; and, providing patient education to increase patients’ ability for self-management and shared decision making.
Compensation will be based on a salary/incentive plan.
Position: Transitions of Care Complex Care Manager RN
Department: Population Health, Care Management
Location: Boston Medical Center Main Campus
Schedule: Full Time, 40 hours, Mon-Fri, Days.
Format: In person, on campus 5 days a week during orientation.
Eligible for 1 remote day per week after successful orientation
ESSENTIAL RESPONSIBILITIES / DUTIES:
Key Functions/Responsibilities:
- Identify and recruit appropriate patients for complex care management from lists and referrals in collaboration with supervisors and local clinical site leaders
- Collaborates with patient and care team to develop a patient-centered care plan, with a particular focus on chronic disease management, social determinants, transitions of care, and advanced care planning (HCP, MOLST)
- Visits hospitalized patients prior to discharge/ transfer to establish relationships, identify needs, and clarify potential discharge plans; provides educational support and coaching.
- Collaborates with community partners, such as VNA agencies, caregiver programs (PCA, ADH, AFC), DME providers, and social service agencies
- Collaborates with outpatient complex care management teams to execute outstanding patient care tasks after hospital discharge.
- Facilitates interdisciplinary consultation on patient’s behalf through participation in rounds, team meetings, and clinical reviews
- Uses reflective, empathetic language and open-ended questions to understand the patient's priorities
- Has knowledge of common chronic medical conditions presented in the population served and is able to:
a. Educate the patient on their medication conditions and medications and build their self-management skills;
b. Use motivational interviewing to promote behavioral change;
c. Assess, triage, and rapidly respond to clinical changes that impact discharge and/or plan of care
- Participates in daily calls with hospital and community-based partners to assist in triage and prioritization of referrals, and with local facility operations, including team meetings, curbsides with care team members, etc.
- Provides expertise and clear recommendations on safe discharge plans for at-risk patients. Helps coordinate the implementation of long-term care plans.
- Actively participates in planning and growth of program with relevant stakeholders as needed, to respond to evolving needs of MassHealth ACO.
- Complies with established metrics for performance and adheres to documentation and workflow standards
- Maintains HIPAA standards and confidentiality of protected health information.
- Adheres to departmental/organizational policies and procedures.
- RN Care Manager will work full-time at the clinical site of care
- Follows established hospital infection control and safety procedures.
- Performs other duties as requested or needed.
Metrics:
- ED and inpatient visits
- Total medical expense
- Patient satisfaction
- Clinical outcomes
- Provider satisfaction
- Avoidable admissions
Other duties as assigned
Qualifications:
Education:
- AD or BS in Nursing
Preferred/Desirable:
- BS or Masters in Nursing
Experience:
A minimum of two years of clinical experience is preferred, ideally within inpatient or insurance based case management
Preferred experience:
- Experience working with vulnerable patient populations
- Home care or ambulatory care nursing
- Motivational interviewing
- Clinical experience working with patients with multiple complex health issues, including substance use disorders and serious mental illness.
Certification or Conditions of Employment:
Licensed to practice professional nursing as a Registered Nurse in the Commonwealth of Massachusetts.
CCM Certification preferred
Competencies, Skills, and Attributes:
- Excellent interpersonal skills and ability to work collaboratively
- Self-management skills, including ability to prioritize and set patient-centered goals
- Excellent written and verbal communication
- Able to maintain professional boundaries
- Ability to work with diverse, safety-net population
- Skilled at engaging difficult-to-engage patients—build rapport, trust
- Creative problem solver
- Ability to adapt to changes in healthcare delivery at local and systems level
- Extensive knowledge of healthcare systems and community resources
- Ability to leverage systems and resources for improved patient outcomes
- Strong organizational and time management skills
Working Conditions and Physical Effort:
- Regular and reliable attendance is an essential function of the position.
Equal Opportunity Employer/Disabled/Veterans
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