Behavioral Health Register Nurse
4 weeks ago
Summary:
The Transitions of Care Team Behavioral Health Focused RN is responsible for managing a patient’s successful transition from hospital or long term BH facility to home and is accountable for developing, implementing, and evaluating comprehensive transitional care interventions for medical and or BH related hospitalizations. 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 BH RN identifies hospitalized high-risk, medically and psychologically complex patients 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, emergency room or program discharge, the TOC BH RN 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. This position's practice directly impacts patient outcomes and FHCW performance measures for Medicaid compliance.
Much of this role will be to continue promoting community connections with local hospitals and programs supporting those with mental health and/or substance use issues. This HIPPA compliant collaboration across health entities will lead to improved communication and care across our health center.
The Transitions of Care Team RN 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 role will also closely align themselves with our psychiatric services program to improve integration and rapidly getting patients into appropriate care.
Educational Requirements:
Graduate of accredited school of nursing required; BS in Nursing preferred.
Experience Required:
Two years full-time professional experience or part-time equivalent.
Professional Licensure/Special Skills And Certification Required:
Must be licensed as a RN by the Massachusetts State Board of Registration. BLS required.
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