Inpatient Heart Failure Care Coordinator
6 days ago
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
- 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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