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Pulmonary Care Nurse Coordinator
2 months ago
At Hackensack Meridian Health, our team members are integral to our mission of enhancing patient care and community health.
We are dedicated to fostering a culture of collaboration and support, where competitive benefits are just the beginning of our commitment to each other and our patients.
The Transitional Nurse Navigator for Pulmonary Care (TNNP) collaborates closely with the medical team, advanced practice providers, and the broader healthcare staff to oversee and assist pulmonary patients and their significant others.
This role is crucial in coordinating, communicating, and facilitating care for patients with primary pulmonary health needs.
The TNNP manages a designated case load through careful selection of eligible patients on a daily basis.They are responsible for assessing, planning, and facilitating care in partnership with patients, families, and healthcare professionals to achieve treatment objectives, while arranging for the necessary subsequent steps.
The TNNP ensures safe and timely transitions for patients across various care levels within the hospital and community.Key Responsibilities
A typical day for a Transitional Nurse Navigator at Hackensack Meridian Health includes:
Collaborating with physicians, nursing staff, and interdisciplinary teams to assess, plan, implement, and evaluate care for selected patients and their families.
Screening:
All patients admitted for medical care will undergo screening for potential eligibility in the pulmonary transitions of care program, with all eligible patients being enrolled.
Patient/Family Assessment:
Conducting direct meetings with patients and families to evaluate needs, utilizing prior assessments from care coordinators and case management to create a tailored needs assessment.
Transitional Care Plan Development: Collaborating with patients, families, caregivers, and the healthcare team to develop a person-centered transitional care plan that maximizes benefits for each patient.
Regularly reassessing and evaluating progress against care goals, making adjustments to the plan as necessary.
Completing all required tasks with precision and in a timely manner.Education:
Providing relevant education to patients and families regarding diagnoses, treatments, and self-management strategies, documenting outcomes in the medical record.
Communication:
Facilitating effective communication and coordination among healthcare team members while involving patients and families in decision-making processes to minimize service fragmentation and manage resources effectively.
Quality Assurance:
Ensuring alignment with patient quality metrics, confirming that patients have primary care and pulmonary providers upon discharge, and making appropriate referrals as needed.
Working collaboratively with all members of the multidisciplinary healthcare team and community partners to ensure timely transitions to the next appropriate level of care, including the TOC unit.
Ensuring follow-up appointments are scheduled with appropriate care providers post-discharge.Resource Networking:
Keeping updated on community resources and referring patients to those that can enhance their clinical outcomes and quality of life.
Consulting with community agencies to identify potential resources for patient and family support. Actively seeking community partners across the care continuum.Documentation:
Accurately documenting patient and family interactions, interventions, and communications in the electronic health record, ensuring it reflects patient needs, education requirements, and follow-up care coordination.
Medical records should indicate that each patient's discharge plan is reassessed in response to any changes in needs and social determinants of health.
Quality Improvement:
Actively participating in relevant workgroups and meetings, contributing positively to problem-solving efforts. Identifying and referring quality issues for review by the pulmonary and transition of care teams.
Monitoring readmission rates and implementing performance improvement projects in collaboration with the pulmonary and medical teams.
Additional duties and projects may be assigned as needed.Adhering to organizational competencies and standards of behavior is essential.
Qualifications
Required Education, Knowledge, Skills, and Abilities:
Bachelor's degree in nursing from an NLN/AACN accredited program.
A minimum of 2 years of experience as a registered nurse, specifically in caring for pulmonary patients or managing chronic/acute diseases.
Excellent critical thinking abilities.
Capacity to thrive in a fast-paced team environment.
Ability to prioritize tasks and manage multiple responsibilities.
Demonstrated capacity to make sound clinical judgments and act professionally under pressure.
Ability to provide age-appropriate care, cultural competency, and effective customer service skills.
Strong written and verbal communication skills.
Proficient in computer skills, including Microsoft Office and/or Google Suite platforms.
Preferred Education, Knowledge, Skills, and Abilities:
Master's degree in nursing or a related field.
At least 2 years of experience as a registered nurse in leadership, education, case/care management, or social work.
Licenses and Certifications Required:
New Jersey State Professional Registered Nurse License.
AHA Basic Health Care Life Support HCP Certification.
Advanced Cardiac Life Support Certification.
Preferred Licenses and Certifications:
Certification in a specialty area (pulmonary/chronic disease management).
Certification in care coordination and/or transitional care.
Project management certification.
