Home-Based Hospital Care RN Care Navigator

4 weeks ago

Middleton, United States Chartwell Midwest Wisconsin Full time
POSITION SUMMARY

The Home-Based Hospital Care Registered Nurse (RN) Care Navigator is an integral part of the Home-

Based Hospital Care clinical team, providing identification, screening, intake, care coordination,

monitoring, and interventions to support acute patients in the home setting. The RN Care Navigator

provides essential intake, clinical review, and care coordination to transition patients from point of

entry, such as but not limited to the Emergency Department, to the Home-Based Hospital Care

program. The RN Care Navigator works in collaboration with the interdisciplinary team including the

Home-Based Hospital Care provider, Home-Based Hospital Care Nurse Manager, Home-Based Hospital

Care RNs, Team Support Coordinator, Social Work, and ancillary services to ensure that patients receive

exemplary care in their home. The RN Care Navigator plays a crucial role in managing all aspects of the

patient’s acute care needs, including coordination of supporting disciplines and ancillary care services.

Interdisciplinary conferencing is facilitated by the RN Care Navigator to ensure that all members of the

care team are actively participating in the patient’s plan of care. The RN Care Navigator provides triage

to the Home-Based Hospital Care patient through various methods of communication, including digital

technology. This position is responsible to provide care for the Home-Based Hospital Care patient

population requiring the use of advanced assessment, technical, teaching, and decision-making skills.

The RN Care Navigator is required to work autonomously and apply critical thinking skills to each patient

during the Home-Based Hospital Care episode of care. The RN Care Navigator is responsible for

assessing post-acute needs and ensuring that appropriate referrals to other services are made.

This position may require evening/weekend hours, and rotating holiday scheduling responsibilities.

JOB REQUIREMENTS

Licenses: Current licensure as a professional nurse in the state of Wisconsin required.

Education: Bachelor’s degree in nursing preferred.

Experience: Minimum of two years nursing experience required.

- Minimum of two years relevant medical surgical clinical nursing, care coordination, or nursing triage experience preferred.

- Recent, relevant experience in home health preferred.

- Experience using EPIC and virtual health platforms preferred.

- Experience in teaching self-care skills to patients and families.

Miscellaneous: Valid driver’s license and current auto insurance required.

- CPR certification required.

- Knowledge regarding the impact of acute and chronic illness on the lives of patients and families in the community.

- Functions with a high degree of independence, flexibility, and autonomy.

- Collaborates with other disciplines to provide care.

- Excellent interpersonal and group process skills.

TECHNICAL RESPONSIBILITIES

· Utilizes monitoring, assessment, planning, intervention, and critical thinking skills to care for acute

care patient populations in the home.

· Works with health system partners to identify, review and intake new Home-Based Hospital Care

patients.

· Navigates patients and families across the continuum of the phases of care.

· Monitors and responds to biometric data per Home-Based Hospital Care protocols.

· Conducts audio/visual patient care visits as directed by the care team and/or protocol.

· Ensures all interventions in the patient’s plan of care are implemented efficiently with a patient

centered approach.

· Leverages the resources and expertise of the Home-Based Hospital Care team and supplier partners

to implement collaborative workflows, standards, policies, protocols, guidelines, and

documentation systems to support safe, reliable, high-quality, evidence-based care with clinical

protocols as the foundation.

· Adheres to the clinical protocols and is willing to obtain the necessary training to provide care within

the context of providing evidence-based care.

· Promotes professional practice and a culture of safety; willingness to engage in process

improvement efforts.

· Provides transitional care responsibilities, as appropriate.

· Directs the use of equipment and supplies in an efficient and cost-effective manner.

· Sets priorities of home and virtual visits, adapting to the changing needs of the Home-Based

Hospital Care patient.

· Utilizes resources to problem solve new or unfamiliar patient situations.

· Works collaboratively with the interdisciplinary team to best meet the needs with the Home-Based

Hospital Care patient and family.

· Documents components of the nursing process to reflect a comprehensive and integrated approach

to nursing care.

· Recognizes potential problems and sets priorities according to changes in the patient’s condition.

· Informs the provider and other appropriate members of the health care team of changes in the

patient’s condition and needs.

· Evaluates patient’s responses to care based on a continuing assessment and analysis of nursing

intervention and alternatives for nursing care.

· Facilitates and participates in formal and informal interdisciplinary care conferences to address the

needs of regarding complex patients.

· Exhibits sound nursing judgment and decision-making skills in coordinating patient care.

· Identifies and adapts teaching materials for Home-Based Hospital Care patients and caregivers to

optimize the learner’s success. Involves the patient and caregiver in identification of individual

requirements/perceptions of learning needs.

· Develops, implements, and evaluates individualized teaching programs using teach-back and return

demonstration techniques to assess patient/caregiver level of understanding and adjust teaching

and plan of care accordingly.

· Maintains an updated clinical record on each patient at all times.

· Participates in the development of program goals and evaluates progress toward goal achievement.

· Participates in committees/meetings as delegated or appointed.

· Involves the patient and caregiver in the plan of care, incorporating their cultural, spiritual, and

other belief systems.

· Recognizes the importance of respecting individual patient and caregiver choices regarding care

and treatment options.

· Assists leadership in identifying potential clinical practice issues and contributes to the

development of specific plans to improve Home-Based Hospital Care patient outcomes.

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