RN - Transition of Care

Job DescriptionJob Description

Position Summary:

The Transitions of Care Team 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, surgical, and/or trauma. They are 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.

The Transitions of Care Team RN identifies high-risk, complex hospital inpatients and outpatients for care management program enrollment and communicates with all entities involved in the care of the patient to promote and maximize care coordination. Upon patient hospital or emergency department discharge, the nurse will complete a post-discharge telephonic follow-up visit with patient, facilitating clinical care, patient’s 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-care, coordination of post-discharge appointments and services (durable medical equipment, home health), and coordination of care across the care continuum. The practice of this position has a direct impact on patient outcomes and FHCW performance measures for Medicare compliance.

The Transitions of Care Team nurse is also responsible for initiating the empanelment process for patients new to FHCW. The RN will assist Providers in obtaining and documenting patients’ comprehensive health and medical history, medication list, screening tests, and other screenings as recommended by the USPSTF and work under the guidance of Providers to ensure continuity of care for all FHCW patients.

This nurse position is a full-time or part-time position and may offer flexible hours and/or the ability to work-from-home.

Essential Duties and Responsibilities:

• Maintains working knowledge of and adhere to the program Manual, agency handbook and Policies and Procedures
• Commitment to providing cost conscious, fiscally responsible, timely, efficient, effective, safe, patient-centered, culturally competent, equitable, and participatory health care.
• Attends all required trainings as per Agency Policy, Program Manual and Funder Guidelines.
• Arrives on time for work and remains at work for whole shift and have regular and predicable attendance.
• Maintains appropriate boundaries and ethical standards with staff, clients, visitors and outside providers as detailed in Agency Policy.
• Maintains positive and professional working relationship with co-workers, managers, clients, visitors and outside providers
• Strong and clear written and verbal communication skills
• Excellent computer skills (included but not limited to Microsoft Word, Excel and Outlook)
• Embodies the following values as set forth in the strategic plan: Compassion, Knowledge is power, equity and inclusion, excellence, courage and capacity to change.
• Acts as a role model to carry out the vision of: Humanity and Healing, provide responsive services, foster opportunities for positive change, bring forward innovation with a purpose, build and promote productive partnerships, strive to be the Employer of Choice, and act as Good Stewards in the communities we serve.
• Any and all other duties as assigned.

Program Specific Essential Duties and Responsibilities:

• Care Coordination: They work closely with the patient's healthcare team, including physicians, nurses, therapists, and social workers, to develop a comprehensive and individualized care plan for the patient's transition. This plan takes into account the patient's medical condition, medications, treatment plan, and any necessary follow-up care.
• Patient Education: Transition of Care Nurses educate patients and their families about the care plan, medications, and any specific instructions or precautions that need to be followed during and after the transition. This is essential to ensure the patient's understanding and compliance with the treatment regimen.

• Medication Management: They review the patient's medications, update medication lists, and address any discrepancies or potential interactions. Ensuring proper medication management is critical to avoid adverse reactions and medication errors during the transition process.

• Communication: They act as a liaison between different healthcare providers involved in the patient's care, ensuring that relevant medical information is communicated effectively and timely. This helps to prevent any miscommunication or gaps in care.
• Follow-up Care: Transition of Care Nurses help schedule and arrange any necessary follow-up appointments or services, such as outpatient visits, home care, or therapy sessions, to support the patient's continued recovery and well-being.
• Discharge Planning: They assess the patient's support system at home and coordinate any necessary medical equipment or home healthcare services to ensure a safe transition and reduce the risk of readmission.
• Advocacy: Transition of Care Nurses advocate for the patient's needs and preferences during the transition process, making sure that their voice is heard, and their rights are protected.
• Risk Assessment: They identify potential risks and challenges that may arise during the transition and work proactively to address them, minimizing the chances of complications or adverse events.

• Strong organizational and communication skills to act as a hub of information across multiple departments.
• Any and all other duties as assigned.

Interpersonal Relationships/Organizational Expectations: 

• Commitment to providing health care to families in a medically underserved community. 
• A willingness to be flexible in the development of new methods of health service delivery.
• Ability to deal with sensitive information in a highly confidential manner. 
• Effective communication skills, both oral and written, with patients, families, visitors,
  co-workers, health care professionals, funders and other regulatory agencies. 
• Bilingual in English and another language appropriate to the health center’s patient
  population preferred, but not required. 
• Ability to function independently with minimal supervision, and to plan, coordinate,
  and complete tasks necessary to meet the job responsibilities. 
• Awareness of resources available within the health center to accommodate the needs of
  patients. 
• Commitment to providing fiscally responsible, timely, efficient, effective, safe,
  patient-centered, culturally competent, equitable, and participatory health
  care.  
• Processes personal health information in accordance with FHCW HIPPA policies and procedures.  

Educational/Leadership Responsibilities: 

Provide guidance to Community Health Worker staff with procedures and activities that facilitate patient centered care and community population health.

Qualifications and Education Requirements

One of the following combinations of education and employment experience must be met in order to be considered for the position:

Education

And

Experience

Graduate of accredited school of nursing required; BS in Nursing Preferred, experienced LPNs will be considered

Two years full-time professional experience or part-time equivalent.

Professional Licensure/Special Skills AND certification required:

• Must be licensed as a RN or LPN by the Massachusetts State Board of Registration. BLS required.

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