Transition of Care Nurse

4 weeks ago


Worcester, Massachusetts, United States Family Health Center Full time
Job Summary

This part-time hybrid position is responsible for managing a patient's successful transition from hospital to home. The Transitions of Care Team nurse is accountable for developing, implementing, and evaluating comprehensive transitional care interventions for high-risk medical, surgical, and/or trauma patients.

Key Responsibilities
  • Care Coordination: Work closely with the patient's healthcare team to develop a comprehensive and individualized care plan for the patient's transition.
  • Patient Education: Educate patients and their families about the care plan, medications, and any specific instructions or precautions that need to be followed during and after the transition.
  • Medication Management: Review the patient's medications, update medication lists, and address any discrepancies or potential interactions.
  • Communication: Act as a liaison between different healthcare providers involved in the patient's care, ensuring that relevant medical information is communicated effectively and timely.
  • Follow-up Care: Help schedule and arrange any necessary follow-up appointments or services to support the patient's continued recovery and well-being.
  • Discharge Planning: Assess the patient's support system at home and coordinate any necessary medical equipment or home healthcare services to ensure a safe transition and reduce the risk of readmission.
  • Advocacy: Advocate for the patient's needs and preferences during the transition process, making sure that their voice is heard, and their rights are protected.
  • Risk Assessment: Identify potential risks and challenges that may arise during the transition and work proactively to address them, minimizing the chances of complications or adverse events.
Qualifications and Education Requirements

One of the following combinations of education and employment experience must be met in order to be considered for the position:

  • Graduate of accredited school of nursing required; BS in Nursing Preferred, experienced LPNs will be considered Two years full-time professional experience or part-time equivalent.
  • Professional Licensure/Special Skills AND certification required:
    • Must be licensed as a RN or LPN by the Massachusetts State Board of Registration. BLS required.


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