Cabell Huntington Hospital is seeking a full-time Nurse Navigator to work with our CHH Home Care Medicine Department.

The Nurse Navigator (NN) position will play a significant role in the post-acute care (PAC) model in the Home Care Medicine model. The NN will provide assistance and expertise when necessary. The NN will be involved in following the patients when they leave the hospital, into a Skilled Nursing Facility (SNF) and then to Home. The following is a model based on the high intensity of volume these nurses will perform:

"Post Acute Care to Skilled Nursing Facility"

• Nurse Navigator visit/phone call within 24 hour

• Nurse Practitioner/Medical Doctor visit within 72 hour then weekly times 4 weeks, more if indicated

• Nurse Navigator attends 72 hour care plan meeting

• Nurse Navigator visits weekly till discharge

• Nurse Navigator coordination with Transition Care Nurse, Chronic Care Management Nurse

• Nurse Navigator attends or manages discharge planning with SNF team

• Nurse Navigator notifies PAC (Post Acute Care) to Home team and Primary Care Provider (PCP) of discharge planning

• Patient graduates to PAC to Home or PAC to Assisted Living Facility program

“Post Acute Care to Home”

• Nurse Navigator visit/phone call within 24 hour

• Nurse Navigator visits each week if has no other RN visit

• Nurse Practitioner visit within 72 hour then weekly times 4 weeks, more if indicated

• Nurse Navigator coordination with Home Health, Transition Care Nurse, Chronic Care Management Nurse (CCM)

• Patient graduates after 30 days, if stable, to CCM program and back to Primary Care Provider (PCP).

"Post Acute Care to Assisted Living Facility"

• Nurse Navigator visit/phone call within 24 hour

• Nurse Navigator visits weekly times 4 weeks, if needed

• Nurse Practitioner/Medical Doctor visit within 72 hour and weekly times 4 weeks, more if indicated

• Nurse Navigator coordination with Assisted Living Facility Nurse, Transition Care Nurse, CCM Nurse

• Patient graduates after 30 days, if stable, to CCM program and back to Primary Care Provider (PCP).