Care Transition Nurse Specialist

4 weeks ago


Westbrook, Maine, United States MaineHealth Full time

About the Role

MaineHealth is seeking a dedicated and compassionate Care Transition Nurse to join our team. As a key member of our care transitions team, you will play a vital role in supporting individuals with dementia and improving the care available to them.

As a Care Transition Nurse, you will engage with patients in the crucial transition from hospital stay back to home. Collaborating with our inpatient care managers and community partners, you will help to improve the health and wellbeing of patients with dementia and ensure continuity of care.

This is a part-time, 24-hour/week, grant-funded position. The ideal candidate will thrive in an independent work environment, be creative and flexible, and have experience working with people living with dementia.

The successful candidate will have a strong understanding of medical procedures, tests, and clinical/clerical skills necessary to perform all functions and assist physicians. They will also possess excellent communication and interpersonal skills, with the ability to organize and accomplish multiple tasks and to have the flexibility to meet changing demands on a daily basis.

Responsibilities

  • Provide ongoing support and expertise through comprehensive assessment, planning, implementation, and overall evaluation of individual patient needs following discharge from the hospital.
  • Collaborate with inpatient care managers and community partners to ensure continuity of care.
  • Develop and implement individualized care plans to meet the unique needs of patients with dementia.
  • Provide education and support to patients and their families to promote healthy behaviors and improve health outcomes.
  • Participate in quality improvement initiatives to enhance the care transitions process.


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