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Transition of Care Nurse
4 weeks ago
Uphams Corner Health Center is seeking a skilled Transition of Care Registered Nurse to join our team. As a Transition of Care Registered Nurse, you will work with a diverse community health population to provide follow-up, education, and outreach to patients post-discharge.
Key Responsibilities:- Conduct outreach to patients after Emergency Department discharge to follow up on their discharge plan and educate about appropriate ED use.
- Review post-discharge plan, screen for social determinants of health, review medication reconciliation, advise on follow-up appointments, and assist patients in obtaining referrals, medications, or other services.
- Assess potential barriers to medication adherence and advise accordingly, demonstrate adequate knowledge of conditions, discharge instructions, and self-care, and address barriers to care (financial, transportation) and follow-up tests.
- Work in collaboration with the Telephonic Triage nurse to prevent unnecessary ED visits, overutilization of ED visits, or hospital admissions.
- Engage patients into the Upham's Community Care health services, reminding them of the health center's hours and educating them about the UCC Urgent Care Department and its hours of operation.
- Communicate and collaborate with other health team providers, including PCPs, specialists, VNA, to facilitate a smooth transition of care.
- Collate and maintain a registry of patients utilizing hospital Emergency Departments.
- Work in collaboration with team structures in Primary Care to obtain same-day or next available appointments for patients as part of follow-up with patients post-ED discharge.
- Deliver patient care and patient education in a manner appropriate to patients' age, physical ability, educational level, and culture.
- Demonstrate clinical competence, self-direction, and sound judgment in the provision of follow-up with patients post-ED discharge.
- Communicate with other UCC staff and departments to ensure comprehensive patient care.
- Maintain communication with Primary Care and Reception regarding hospital discharge patients being readily accommodated for return visits and follow-up care to prevent potential unnecessary use of the ED.
- Document all care and advice in patients' electronic medical records.
- Complete required forms for medical and billing purposes and ensure current patient record keeping.
- Cooperate with all health center departments, affiliated hospitals, and other community agencies.
- Maintain patient confidentiality at all times.
- Participate in regularly scheduled team meetings and department meetings.
- Maintain current knowledge of developments in the nursing field and be responsible for self-development through continuing education programs.
- Participate in on-going quality assurance and performance improvement initiatives related to tracking and measuring success and facilitate appropriate response strategies with other clinical team members for the initiatives to reduce overall frequent ED use.
- Licensed Registered Nurse (B.S.N. preferred) in Massachusetts.
- Two years of nursing experience, preferably in an ambulatory care, emergency department, or community health setting.
- Experience in a culturally diverse setting.
- Bilingual language skills in English/Spanish, English/Portuguese/Cape Verdean Creole, or English/Vietnamese preferred.
