Nurse 3/Hospital Liaison Nurse

Job Description:
Nurse 3/Hospital Liaison Nurse

Come work in an environment where we truly value and respect those we serve and believe in the mission that all people can achieve a higher level of wellness and independence.
The state supported living centers serve people with intellectual and developmental disabilities who are medically fragile or who have behavioral problems. The centers provide campus-based direct services and supports at 13 centers located throughout the state.

The state of Texas offers many benefits to employees. HHSC is a qualifying organization for the Federal Public Service Loan Forgiveness Program, which forgives the remaining balance on college student Direct Loans after making qualifying monthly payments. We also offer excellent health benefits, a lifetime monthly retirement annuityas well as (k) and Programs under the Employees Retirement System of Texas.
If you are looking for a place to work where you can establish a career that is filled with purpose, this is the job for you

Free CEUs and updated resources through Lippincott access for all nurses.

The Nurse III, Hospital Liaison Nurse (HLN) performs highly complex (senior-level) nursing work within the scope of practice attributed to the skills of a registered nurse. Coordinates and organizes nursing services and activities related to SSLC individuals receiving care in hospitals or other healthcare facilities. Conducts outreach and liaison activities at hospitals and local healthcare facilities used by the SSLC, making hospital rounds in accordance with the needs of the individuals, the schedule of the hospital and the guidelines established by the SSLC. Observes hospitalized individuals while making rounds and gathers all pertinent information on medical and mental condition, behaviors, equipment, and other needs, and takes appropriate follow-up action. Provides consultation, training and technical assistance to the assigned DSP, sitter and/or other designated person to ensure quality supports and services are provided to the individual during the hospitalization. Communicates findings and recommendations to all involved disciplines. Facilitates discharge planning, serving as a liaison to ensure optimal flow of information. Attends and/or provides information to a designee for meetings related to the status and care of the hospitalized individual(s). Reviews medicals records and collaborates with other to reconcile any discrepancies. Completes and/or oversees the completion of required reports and documentation. Develops, reviews, revises, and explains policies, procedures and protocols related to hospitalizations and makes recommendations to the CNE/NOO on how to improve processes to ensure quality services for individuals. Provides treatment to HHS employees injured in course and scope of employment. Takes calls from hospitals as needed and SSLC as assigned. This position is supervised by the Chief Nurse Executive or Nurse Operations Officer. Works under limited supervision, with considerable latitude for the use of initiative and independent judgment.
Essential Job Functions:
Attends work on a regular basis and may be required to work a specific shift schedule or, at times, even a rotating schedule, extended shift and/or overtime in accordance with agency leave policy and performs other duties as assigned. Takes calls from hospitals as needed. May serve in an on-call status on a rotating schedule as required to meet operational needs of the facility.

Coordinates and organizes nursing services and activities related to individuals receiving care in hospitals or other healthcare facilities. Maintains professional relationships with key contact sources at local hospitals, exchanging information with hospital/health care facility staff. Communicates, as needed and in accordance with local protocols, with the designated SSLC staff regarding Direct Support Professional (DSP) schedules if DSP coverage at the hospital is required. Ensures the SSLC has an updated list of individuals hospitalized. Follows local SSLC policies and protocols to ensure pertinent information is shared with SSLC staff and guardians/ Legally Authorized Representatives (LARs). Develops, reviews, revises, and explains policies, procedures and protocols related to hospitalizations. Assists in developing guidelines for the hospital liaison position as assigned. Makes recommendations to the CNE/NOO on how to improve hospital liaison processes to ensure quality services for individuals. Ensures at least one designee is cross trained to perform hospital liaison duties.

Conducts outreach and liaison activities at hospitals and local healthcare facilities used by the SSLC. Makes hospital rounds in accordance with a schedule determined by the needs of the SSLC and circumstances of the individuals, typically daily Monday through Friday. When/if physical rounds are not feasible (such as weekends, holidays, or due to the distance to the hospital), calls for verbal reports. Serves as the professional representative of the SSLC when making rounds or other interactions with hospital/healthcare facility staff. Is available by phone, in accordance with local on-call schedules, to answer (or seek answer to) any pertinent questions from SSLC staff/DSP and/or hospital staff/physicians such as questions about complicated cases, medication issues, history, and discharge planning. Ensures hospital staff have pertinent information and documentation from the SSLC.

Observes hospitalized individuals while making physical rounds and gathers pertinent information. Collects all pertinent information related to the patient including, but not limited to, behaviors, restraints performed, procedures performed or planned, current clinical conditions such as lung sounds, vital signs, weight, HIPAA codes, IV medications, home medication changes, safety concerns, equipment needs, condition of skin including documenting any wounds. Obtains clinical hospital records when needed. Confirms hospital has accurate facility documentation such as current home medication list, immunization and allergy records, diet information, respiratory needs, and if not present, provides it as soon as possible for their review. To the extent possible at a host site, ensures that prescribed methods and procedures are followed and that an appropriate standard of care and quality of service is being provided. Reports any concerns to the CNE/NOO.

Provides consultation, training and technical assistance to the assigned DSP, sitter and/or another designated person. Develops inservice training and health education strategies related to the assigned individual(s) and locates resources to assist in hospital stay and transition back to the SSLC. Discusses the hospitalization, reviews any notes, and educates assigned staff on relevant information concerning the individual(s), including signs and symptoms to observe for and report to a nurse. Confirms a copy of the Physical and Nutritional Management Plan (PNMP) is in room with individual and available to those who need it. Confirms that all needed adaptive equipment is at the hospital, and if not, requests it to be sent to the hospital as soon as possible. When warranted, instructs, counsels, and assists hospitalized individuals in meeting their health care needs.

Communicates findings and recommendations to hospital nurses, physicians, and SSLC Primary Care Providers (PCP) and other staff as necessary. Discusses any pressing issues or concerns that are found with primary nurse and educates the primary nurse or designee, when needed, about the individual’s unique care needs. Discusses any discharge planning issues or concerns with the hospital’s case manager or appropriate designee. If hospital physicians or consultants are available, communicates and discusses the plan of care for that individual. Answers questions about facility care and discharge planning generally and those specific to the individual. Coordinates discharge planning with the IDT including habilitation therapy staff, the RN Case Manager and the SSLC PCP. Communicates effectively with hospital staff for updates and facilitates the completion of the communication loop.

Attends and/or provides information to a designee for meetings related to the status and care of the hospitalized individual(s) such as daily morning medical and Incident Management Review Team (IMRT) meetings to ensure medical issues or concerns are addressed promptly. Receives information from team members at these meetings and conducts follow up with the hospital or health care facility to address and resolve issues and/or take next steps in the best interest of the individual. (10%)

Attends and/or provides information to a designee for the Interdisciplinary Team (IDT) meeting for each hospitalized individual. Communicates with members of the IDT regarding the health status of the individual including changes in treatment plan and anticipated discharge. Initiates early interaction with the IDT for planning the individual’s discharge back to the SSLC as directed by healthcare provider. Documents communications with the IDT members in the Hospital Liaison Report. Develops discharge plan strategies for individual in preparation for discharge back to center home and/or other setting in coordination with the interdisciplinary team. Communicates daily with the medical director/PCP regarding each individual to ensure PCP has adequate information to fully determine the individual’s needs prior to their discharge back to the SSLC facility. Plans for any staff training/supplies/equipment/treatments, etc. that will be needed prior to return to facility.

Completes and/or oversees the completion of required reports and documentation. Completes Hospital Liaison Reports in IRIS on all hospitalized individuals, including data gathered such as from hospital nurse, DSP, observations, and Electronic Medical Record (EMR) review. Includes discharge planning discussions with hospital staff, SSLC staff and any other involved entities such as hospice. Ensures the completion of the Medical Transfer Form. If required by SSLC leadership, updates Hospital/ER tracking spreadsheet daily. Collaborates with the assigned pharmacist to complete, medication reconciliation between hospital and SSLC on all home medications. If discrepancies are found, makes and documents appropriate calls to hospital primary nurse, charge nurse, manager and/or physician. Completes other reports as required by local protocols. Maintains and stores records in accordance with retention schedules.

Based on the needs of the SSLC, serves or chairs on other committees as assigned such as Root Cause Analysis (RCA), wound care meetings when wounds appear during hospitalizations, and state-wide hospital liaison meetings. Assists with regulatory survey and Department of Justice (DOJ) monitoring visits by confirming the list of hospital admissions, Hospital ER visits or other hospitalization related data are correct.

Provide direct care nursing services as needed. Administers medication, immunizations, and treatment, and observes patients for unusual symptoms and reactions. Provides treatment to HHS employees injured in course and scope of employment.
Other duties as assigned include but are not limited to actively participating and/or serving in a supporting role to meet the agency’s obligations for disaster response and/or recovery or Continuity of Operations (COOP) activation. Such participation may require an alternate shift pattern assignment and/or location.
Knowledge Skills Abilities:
•Considerable knowledge of nursing techniques, standards, and procedures; of health care laws and regulations; of medical diagnoses and procedures; of accepted medical treatment patterns; of community health and nursing care principles, practices, and procedures; of program regulations and procedures; and of utilization review and control measures.
•Knowledge of nursing care standards, the Settlement Agreement, and the Healthcare Guidelines or ability to quickly gain the knowledge.
•Knowledge of state and federal laws and Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF-IID) rules, regulations, policies, and procedures related to SSLCs or ability to quickly gain that knowledge.
•Knowledge of emergency procedures and emergency equipment, i.e., Cardiopulmonary Resuscitation (CPR), and ability to assess and care for residents and/or staff members in emergency situations.
•Skill in the use of computer/software and an electronic health record system.
•Skill in writing policy, procedures and guidelines.
•Excellent verbal and written communication skills and the ability to present ideas clearly and concisely in both written and oral communications.
•Skill in the care and treatment of patients.
•Ability to provide patient care; to prepare and maintain records; to organize, coordinate, and evaluate nursing activities and delivery of health services; to interpret policies and procedures; to interpret health care regulations; to recognize patterns of medical necessity treatment; and to provide technical assistance and consultation to others.
•Ability to interpret regulations and communicate them effectively both orally and in writing.
•Ability to appropriately interact with individuals with intellectual/developmental disabilities, with their family members, with staff members and with staff members in a host organization (i.e. community healthcare facility/hospital).
•Ability to work independently and productively with all levels of staff.
•Ability to train/in-service all levels of staff.
•Ability to make recommendations to SSLC leadership including on-call administrators.
•Must maintain current CPR certification. Must have strength and flexibility to safely perform CPR.
•Ability to work independently and productively with all levels of staff.

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