Transitional Care Nurse, LPN
Found in: Lensa US P 2 C2 - 2 weeks ago
Job Description
Job Description
POSITION
SUMMARY
Faculty and Residents from the University of Kansas School of Medicine--Wichitas Internal Medicine Department provide patient care primarily through our clinic. We are dedicated to continuous quality improvement while providing high quality, efficient health care to patients. The Transitional Care Nurse will be responsible for managing KU Internal Medicine patients transition process from inpatient hospital care to outpatient care. Outpatient care includes discharges to intermediate and temporary care facilities including, but not limited to, KU MPA ambulatory care clinics, skilled nursing facilities (SNF), nursing homes, long-term care facilities (LTCF), and assisted living facilities. Inpatient care will be provided at Ascension Via Christi St. Francis (AVCSF) Hospital and Wesley Medical Center (WMC). It is expected the Transitional Care Nurse would round between one or both hospitals (as assigned) and work with the patients respective medical team and ancillary teams to coordinate each patients transition of care.
ESSENTIAL FUNCTIONS
General Responsibilities:
Complies with hospital policies and guidelines required for privileging and accessing facilities
Identifies patients eligible for Transitional Care Management (TCM) and enrolls appropriate patients into TCM program
Works with KU Internal Medicine (IM) Hospitalist providers to identify patients who are not eligible for TCM but require ongoing follow-up care coordination through KU IM or GI clinics
Manages Transitional Care patient dashboard
Monitors all aspects of patient care including diet, physical activity, medication
accessibility/afford -ability, and care coordination
Works with patients, groups, or families to plan or implement safe and effective transition of care plans
Schedules and confirms appointments for patients by coordinating with clinic office staff, ancillary providers, and primary care providers
Determines best level of outpatient care for individual patients, i.e., requires PCP visit or interprofessional shared visit
Attempts two phone calls to discharged patients within 2 business days post-discharge (if discharged home)
Attempts two phone calls to discharged patients within 2 business days post-discharge from a temporary care facility (if notified of their discharge)
Coordinates care with clinic staff, communicating patient needs and barriers to care
Documents all patient encounters in the appropriate electronic medical records systems, maintaining accurate, detailed reports and records
Maintains scheduling and event calendars
Provides or arranges for training or instruction of auxiliary personnel as scheduled
Engages in research activities related to nursing; if applicable
Participates in clinic process improvement activities and team meetings to ensure efficient operations
Reliable attendance and punctuality
Performing other duties as assigned
POSITION QUALIFICATIONS
Certificates & Licenses:
Kansas licensed LPN
Education:
Associates degree (two-year college or technical school)
Experience:
Minimum two (2) years nursing experience required
Three to five years experience in clinical or community health settings preferred
Previous experience in caring for chronic disease patients required
Previous experience in Care Coordination, Case Management or Home Health preferred
Experience with navigation of local medical and social support systems preferred
Experience with health systems and data reports preferred
Bilingual in English and Spanish preferred
EHR experience required (we use eClinicalWorks)
Microsoft Office experience is essential for database management and word processing
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