Care Transition Registered Nurse
4 weeks ago
The Care Transition Registered Nurse plays a crucial role in overseeing a patient's effective shift from hospital care to home recovery. This position is dedicated to crafting, executing, and assessing thorough transitional care strategies for patients with high medical, surgical, or trauma-related risks. The nurse is tasked with managing the post-acute care of patients who are vulnerable to adverse health outcomes, recurrent emergency visits, and hospital readmissions, while navigating complex patient scenarios.
The Care Transition RN identifies high-risk hospital inpatients and outpatients for enrollment in care management programs, ensuring seamless communication among all parties involved in the patient's care to enhance and optimize care coordination. Following a patient's discharge from the hospital or emergency department, the nurse conducts a telephonic follow-up to facilitate clinical care, ensure access to necessary services, and arrange referrals and appointments. This includes a strong emphasis on medication reconciliation and adherence, quality of life management, chronic and acute disease oversight, identification and resolution of care gaps, assessment of the patient's self-care capabilities, and coordination of post-discharge services and appointments. The effectiveness of this role significantly influences patient outcomes and compliance with performance measures.
The Care Transition RN is also responsible for initiating the empanelment process for new patients. This involves assisting healthcare providers in gathering and documenting comprehensive health histories, medication lists, and recommended screenings, all while working under the guidance of providers to ensure continuity of care for all patients.
This position can be offered on a full-time or part-time basis.
Key Responsibilities:
- Maintain a thorough understanding of and comply with the program manual, agency handbook, and established policies and procedures.
- Demonstrate a commitment to delivering cost-effective, timely, efficient, safe, patient-centered, culturally competent, and equitable healthcare.
- Participate in all mandatory training sessions as per agency policy and funding guidelines.
- Uphold professional boundaries and ethical standards in interactions with staff, clients, visitors, and external providers.
- Foster positive and professional relationships with colleagues, management, clients, and external stakeholders.
- Exhibit strong written and verbal communication skills.
- Possess excellent computer proficiency, including but not limited to Microsoft Word, Excel, and Outlook.
- Embody the core values outlined in the strategic plan: compassion, empowerment through knowledge, equity and inclusion, excellence, courage, and adaptability.
- Serve as a role model in realizing the vision of humanity and healing, providing responsive services, fostering opportunities for positive change, and promoting innovation with purpose.
- Care Coordination: Collaborate closely with the patient's healthcare team, including physicians, nurses, therapists, and social workers, to formulate a comprehensive and individualized care plan tailored to the patient's transition needs.
- Patient Education: Educate patients and their families about the care plan, medications, and specific instructions or precautions necessary during and after the transition.
- Medication Management: Review and update the patient's medication list, addressing any discrepancies or potential interactions to ensure safe medication practices.
- Communication: Act as a liaison among various healthcare providers to ensure timely and effective communication of relevant medical information.
- Follow-up Care: Assist in scheduling and coordinating necessary follow-up appointments or services to support the patient's ongoing recovery.
- Discharge Planning: Evaluate the patient's home support system and coordinate any required medical equipment or home healthcare services for a safe transition.
- Advocacy: Advocate for the patient's needs and preferences throughout the transition process, ensuring their voice is heard and rights are upheld.
- Risk Assessment: Identify potential risks during the transition and proactively address them to minimize complications.
- Demonstrate strong organizational and communication skills to serve as a central information hub across multiple departments.
To be considered for this position, candidates must meet one of the following combinations of education and experience:
Education:
Graduate of an accredited nursing program required; a Bachelor of Science in Nursing is preferred. Experienced LPNs will also be considered.
Experience:
Two years of full-time professional nursing experience or part-time equivalent.
Licensure and Certification:
- Must hold a valid RN or LPN license from the Massachusetts State Board of Registration. BLS certification is required.
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