Description

Position Title: Transition of Care Registered Nurse
Department: Nursing
Supervisor: Director of Nursing
Hours per week: 40

Primary Function:
The Transition of Care RN works with a diverse community health population to provide follow-up, education, and outreach to patients post discharge; collates and maintains a registry of patients; gives provider support services; works collaboratively in support of team structures within the Primary Care Department and in conjunction with other RNs and primary care providers to: 1) assist in the treatment plan for the episode/condition that brought about the visit and 2) prevent future visits. The aim of this role is to provide support and coordination of services to patients to improve their overall quality of care.

Duties & Responsibilities:

• Conduct outreach to patients after Emergency Department (ED) discharge in order to follow up on their discharge plan and educate about appropriate ED use.
• Review post discharge plan; screen for social determinants of health; review medication reconciliation; advise on follow up appointment(s); assist patient in obtaining referrals, medications or others' services that may apply.
• Assess potential barriers to medication adherence and advise accordingly, demonstrate adequate knowledge of condition(s), discharge instructions and self-care; and address barriers to care (financial, transportation) & follow-up tests.
• Work in collaboration with the Telephonic Triage nurse to prevent unnecessary ED visits, overutilization of ED visits or hospital admissions.
• Engage patients into the Upham’s Community Care health services, reminding the patient of the heath center’s hours and, along with education about the UCC Urgent Care Department and its hours of operation.
• Communicate and collaborate with other health team providers including PCPs, specialists, VNA etc. to facilitate a smooth transition of care.

• Collate and maintain a registry of patients utilizing hospital Emergency Departments.
• Work in collaboration with team structures in Primary Care to obtain same day or next available appointment for patients as part of follow-up with patient post-ED discharge.
• Deliver patient care and patient education in a manner that is appropriate to patient’s age, physical ability, educational level, and culture. Demonstrate proficiency in adapting care to meet the needs of the following patient populations: neonatal, pediatric/adolescent, adult, or geriatric.
• Demonstrate clinical competence, self-direction and sound judgment in the provision of follow-up with patient post-ED discharge.
• Communicate with other UCC staff and departments to ensure comprehensive patient care.
• Collaborate with Reception/Call Center staff to book return appointments for patients as necessary.
• Maintain communication with Primary Care and Reception regarding hospital discharge patients being readily accommodated for return visits and follow-up care to prevent potential unnecessary use of the ED.
• Document all care and advice in patient’s electronic medical record.
• Complete required forms for medical and billing purposes and ensure current patient record keeping.
• Cooperate with all health center departments, affiliated hospitals, and other community agencies.
• Maintain patient confidentiality at all times.
• Participate in regularly scheduled team meetings and department meetings.
• Maintain current knowledge of developments in nursing field and be responsible for self-development through continuing education programs.
• Participate in on-going quality assurance and performance improvement initiatives related to tracking and measuring success and facilitate appropriate response strategies with other clinical team members for the initiatives to reduce overall frequent ED use.
• Perform other related duties as required.

Qualifications

Minimum Basic Knowledge: Licensed Registered Nurse (B.S.N. preferred) in Massachusetts.

Experience & Qualifications:

• Two years of nursing experience, preferably in an ambulatory care, emergency department or community health setting.
• Experience in a culturally diverse setting.
• Bilingual language skills in English/Spanish, English/Portuguese/Cape Verdean Creole or English/Vietnamese preferred.

Independent Action:

• Functions independently within scope of nursing practice and health center policies and goals.
• Refers specific problems to supervisor when clarification of operating polices or procedures is required.

Supervisory Responsibility:

• There are no supervisory responsibilities.

Define Access Level to PHI:

Level 4 [Authorized to access full health information. UCC position and job responsibilities involve the provision of patient care and working as a clinical team member. Staff in this category level, although allowed full access, should only access the necessary information for each respective treatment encounter/circumstance].