Definition:

This role is responsible for facilitating patient transitions including inpatient and outpatient settings. The Transitional Care Nurse will participate in identification of appropriate patients; encourage patient and family engagement in self-care management; promote warm handovers to the next level of care by providing family timely, pertinent information in a standardized way; conduct patient and family education of key elements of the patient’s personal care plan by “teach-back” methodology and follow-up phone calls and assist the patient in navigating the healthcare system, ensuring follow-up visits are scheduled and attended. This role is designed to improve effectiveness and efficiency during transitions of care and supports the elements required in delivering highly coordinated patient centered care.

Line of Authority:

Administrator; Director of HomeCare; Vice President, HomeCare

Qualifications:

1. Licensed Registered Nurse or Licensed Practical Nurse
2. Required time in field previous to employment: 5 years in a combination of inpatient and outpatient experience

Performance Requirements:

1. Able to see and hear adequately in order to respond to auditory and visual requests that relate to the coordination of job requirements.
2. Able to speak in clear, concise voice in order to communicate requirements and goals to HomeCare Administrators/Directors of Services and staff.
3. Mental acuity high enough to adequately perform job requirements.
4. Able to learn, absorb, and apply professional training.
5. Able to independently organize work procedures, assume responsibility and tactfully interact with others.
6. Must have reliable transportation and the ability to travel regularly within the region.

Specific Responsibilities:

Planning and Managing

1. Coordinates the evaluation process of the defined patient population.
2. Assists in identification of appropriate patient population through chart review, data analysis and direct communication with providers and teams.
3. Facilitates appropriate resource utilization.
4. Maintains comprehensive documentation of evaluation process for presentation to multidisciplinary care planning conference, making recommendations for standardized versus enhanced care.
5. Participates in multi-disciplinary meetings in multiple settings.

Continuum of Care

1. Supports patient access by serving as a liaison between NHC HomeCare and other assigned facilities.
2. Interacts routinely and effectively with the clinical teams to develop a collaborative plan for the transition of the patient from facility care to home.
3. Assesses patients (clinically, for adherence, social factors), reviews, and actively participates in development of a transitions plan.
4. Assists with transition in collaboration with a multi-disciplinary team.

Patient and Family Education

1. Communicates information to patients and/or caregivers regarding the plan of care through transitions.
2. Assists in the development and dissemination of patient education materials/information.
3. Meets face to face with patients and families, developing relationships with the intent of providing timely education utilizing the teach-back methodology as a means to reduce anxiety, increase self efficacy, and identify limitations requiring intervention from the care team during the transition.
4. Engages patient and family in transition management, serving as the patient’s consistent, easily accessible point person.

Problem Solving

1. Per standards of practice, demonstrates sound clinical judgment and disease expertise to assess and resolve problems in collaboration with the multidisciplinary team.
2. Implements performance improvement action plans and collects data for analysis for further improvement opportunities.

Communication and Collaboration

1. Clearly and efficiently communicates significant information with team members and staff; including: appropriate handoff of information to involved personnel, following established guidelines and resolution procedures.
2. Demonstrates effective use of equipment (computer, telecommunications), appropriate tools, and verbal presentation skills to thoroughly document and communicate with team members and staff.
3. Maintains routine communication with leadership regarding concerns, improvements, or any job performance needs.
4. Educates healthcare team regarding patient plan of care including transition plans, discharge process, teaching goals, and overall expectations for managing defined patient population.

Continuous Self and Systems Learning

1. Develops and achieves personal and professional goals, while also contributing to the overall departmental goals.
2. Participates in on-going quality improvement activities such as data collection, outcomes management, readmission surveillance.
3. Evaluates performance against established benchmarks for cost, LOS, and quality outcomes.