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Heart Failure Transition Specialist

2 months ago

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

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

Key Responsibilities
  • Inpatient Care
    • Identify eligible patients 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 heart failure guideline-directed medical therapies plans
  • Transitions of Care
    • Collaborate with the inpatient care team to develop discharge care plans
    • Coordinate post-discharge care to ensure a 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
  • Post-Discharge Care
    • Call patients by phone at pre-determined intervals to ensure adherence with care plans
    • Communicate closely with patients and their families during the first 30 days post-discharge to ensure they are fully informed and supported
    • Remind patients of upcoming appointments
    • Help resolve obstacles to adherence and well-being
  • Data Collection
    • Collect and document key data points into appropriate systems
    • Help provide quality assurance of 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 with heart failure
    • Participate in the development and evaluation of program tools and interventions
    • Provide educational in-reach and outreach to providers in the network
    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