Pulmonary Care Transition Specialist
2 weeks ago
Position Summary:
At Hackensack Meridian Health, our workforce is the cornerstone of our success.
We are dedicated to enhancing the lives of our patients while fostering an environment where our team members can thrive.
Together, we strive for continuous improvement, advancing our mission to revolutionize healthcare and lead positive change.
The Pulmonary Care Transition Specialist (PCTS) works closely with the medical team, advanced practice providers, and the broader healthcare network to oversee and assist pulmonary patients and their families.
The PCTS is an integral part of the healthcare team, responsible for coordinating, communicating, and facilitating care for patients with primary pulmonary needs.
The PCTS manages a specific caseload determined by the careful selection of eligible patients on a daily basis.They assess, plan, and facilitate care in collaboration with patients, families, and healthcare professionals to achieve treatment objectives, while arranging for appropriate subsequent steps.
This role promotes safe and timely transitions for patients across various care levels within the hospital and community.Key Responsibilities:
A typical day for a Pulmonary Care Transition Specialist at Hackensack Meridian Health includes:
Engaging in collaboration with physicians, nursing staff, and interdisciplinary teams to assess, plan, implement, and evaluate care for selected patients and their families.
Eligibility Screening:
All patients admitted for medical care will undergo screening for potential inclusion in the pulmonary transitions of care program. All eligible patients will be enrolled.
Patient/Family Assessment:
Conducts direct meetings with patients and families to evaluate needs, based on prior assessments from care coordinators and case management, and develops a tailored needs assessment.
Transitional Care Plan Development: Collaborates with patients, families, caregivers, and the healthcare team to create a transitional care plan that maximizes benefits for each patient.
Regularly reassesses and evaluates progress against care goals, revising plans or objectives as necessary.
Completes all other required tasks with precision and in a timely manner.Patient Educator:
Delivers relevant education to patients and families regarding diagnoses, treatment options, and self-management strategies, documenting outcomes in the medical record.
Effective Communicator:
Facilitates communication and coordination among healthcare team members, involving patients and families in decision-making processes to minimize service fragmentation, manage resources, and eliminate barriers to discharge plans.
Quality Transition and Assurance:
In alignment with patient quality metrics, ensures that patients have a primary care provider and pulmonary specialists upon discharge, making appropriate referrals as needed.
Collaborates with all members of the multidisciplinary healthcare team and community partners to ensure timely and suitable transitions to the next level of care, including the transitional care unit.
Ensures timely follow-up appointments with relevant care providers post-discharge.Resource Networking:
Maintains up-to-date knowledge of community resources and refers patients to those that will enhance their quality of life and clinical outcomes.
Consults with community agencies and committees to identify potential resources to support patients and their families. Provides patients and families with information on community resources and discharge care coordination options. Actively seeks community partners across the care continuum.Documentation:
Accurately documents patient and family interactions, interventions provided, and communications in the electronic health record.
The electronic health record will reflect patient needs, any required education based on medical history, coordination of follow-up care, and referrals to community services.
Medical records will indicate that each patient's discharge plan is reassessed in response to changes in needs and social determinants of health.
Quality Assurance and Program Development:
Actively participates in relevant workgroups and meetings. Demonstrates positive problem-solving skills. Identifies and refers quality issues for review by the pulmonary/medical and transition of care teams.
Monitors readmission rates for Medicare and all payers, implementing necessary performance improvement projects in collaboration with the pulmonary/medical team.
Other duties and projects as assigned.Adheres to organizational competencies and standards of behavior.
Qualifications:
Education, Knowledge, Skills and
Required Abilities:
Bachelor's degree in nursing from an NLN/AACN accredited program.
A minimum of 2 years of experience as a registered nurse, particularly in the care of pulmonary patients or chronic/acute disease management.
Excellent critical thinking abilities.
Capacity to work in a fast-paced team environment.
Ability to prioritize and manage multiple tasks.
Ability to make sound, independent clinical judgments and act professionally under pressure.
Demonstrated ability to provide age-appropriate care, cultural competency, customer service skills, and health literacy.
Exceptional written and verbal communication skills.
Proficient in computer skills, including Microsoft Office and/or Google Suite platforms.
Education, Knowledge, Skills and
Preferred Abilities:
Master's degree in nursing or a related field.
A minimum of 2 or more years of experience as a registered nurse in leadership, education, case/care management, or social work.
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