Inpatient Heart Failure Care Coordinator

6 days ago


Boston, Massachusetts, United States Tufts Medical Center Full time
Job Overview

This position plays a critical role in coordinating the transition of care from one healthcare setting to another, ensuring seamless continuity of care for patients with heart failure. The ideal candidate will have a strong background in nursing and experience working with heart failure patients.

Key Responsibilities
  • Inpatient Care
    • Identify eligible inpatients using established program criteria
    • Deliver education to patients and caregivers, including teach-back interventions
    • Perform risk assessment using standardized tools
    • Support non-cardiology primary providers with HF guideline-directed medical therapies plans, including liaison with pharmacy
  • Transitions of Care
    • Collaborate with other members of the inpatient care team to develop discharge care plans
    • Coordinate post-discharge care to ensure seamless transition
    • Collaborate with pharmacists on medication reconciliation
    • Schedule post-discharge clinic appointments
    • Communicate with patient's primary care physicians and post-acute care providers regarding post-discharge care expectations
    • Develop plans for scheduled check-ins with patients and caregivers
  • Post-Discharge Care
    • Call patients by phone at pre-determined intervals
    • Ensure patient adherence with care plans (e.g., medications, self-monitoring)
    • Communicate closely with patients and their families during the first 30 days post-discharge to ensure they are fully informed and supported during the transition period
    • Remind patients of upcoming appointments
    • Help resolve obstacles to adherence and well-being
  • Data Collection
    • Collect and document key data points into appropriate systems (e.g., risk assessment scores)
    • Help provide quality assurance of appropriate systems to ensure data integrity
    • Perform interval reviews of readmission cases to identify opportunities for improvement
  • Program Development
    • Recommend improvements or development of standards of practice for inpatient, post-acute, home, and ambulatory care of patients
    • Participate in the development and evaluation of program tools and interventions, such as patient education materials, risk assessment tools, and databases
    • Provide educational in- and outreach to providers in the network
    • Work in collaboration with heart failure disease management nurses and other healthcare professionals
    Requirements
    • Bachelor of Science degree in Nursing
    • Registered nurse with current unrestricted Massachusetts state license
    • Heart failure nurse certification highly desirable
    • Minimum of 5 years of clinical nursing experience working with heart failure cardiology patient populations


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