Transition of Care RN Liaison - Home Health - Full Time/Days - Req#2063919739

Job Objective:

Responsible for the successful clinical coordination of care for patients requiring Outpatient IV therapy. Facilitated communication between Antelope Valley Medical Center (AVMC), the patient and/or family, and the Infusion Services. Collaborates with prescribing providers and affiliated staff and pharmacy staff to facilitate the coordination of care for patients.

Essential Duties and Responsibilities:

1. Patient Care Education and Coordination

• Identification of appropriate patient for outpatient infusion services.
• Provide patient education and training regarding therapy and supplies, as well as clarifying expectations of care provided.
• Educate the patient/family about the patient’s care needs and disease prevention.
• Use the nursing process to plan and provide patient/family care. This includes assessing and evaluating needs and implementing effective care plans which are kept up to date, evaluated and documented.
• Coordinate patient care activities and maintain communication with other disciplines including nursing agency, pharmacist and physician.
• Evaluates current and future clinical and service needs for patients and prescribing clinicians.

2. Documentation

• Appropriately documents the coordination of care activity, including but are not limited to:
• Infusion Nursing services utilized.
• Obtains radiology report for PICC placement and reviews/submit to pharmacy.
• All communication with patients, referral sources, physicians, and infusion staff.
• All patient and/or caregiver education and training.
• Maintains up to date records, as well as any other requested records in accordance with business goals.

3. Communication

• Coordinates and communicates all discharge planning activities for new patient referrals, including, but not limited to:
  • Intake
  • Clinical Operations: Pharmacy and/ or Nursing
  • Reimbursement
• Maintain effective lines of communication between hospital staff, physicians, and infusion staff.
• Obtains and inputs orders from physicians and verifies accuracy of the order. Inputs pharmacy protocol for saline/heparin flushes and PICC line removal once therapy is complete.
• Checks lab results for availability of blood culture reports and communicates results to the physician.
• Reviews patient history for illicit drug use and develops a safety contract if indicated.

4. Case Management

• Acts as a resource to physicians and nursing staff regarding patient’s transition of care.
• Coordinates with staff and pharmacy to ensure initial dose of medication is provided to the patient prior to discharge and/or arrange an anaphylactic kit delivery if first dose is not administered in the hospital.
• Coordinates IV medications schedule prior to discharge.
• Coordinates with OPTC to ensure PICC line is scheduled and in place prior to inpatient discharge.
• Coordinates with pharmacy regarding delivery of medications.
• Develops, maintains, and grows core therapy and service line admissions.

Non-Essential Duties:

• Participates in Quality Improvement (QAPI) process as requested in utilization review (UR), chart audits and Performance Improvement committees.
• As appropriate and/or required, participates in continuing education programs and in-services regarding therapy programs.

Knowledge, Skills, and Abilities:

Knowledge

• Knowledge of in-patient processes, nursing care and discharge planning.
• Knowledge of home health care and IV Therapy.
• Knowledge of medications, indications, dosage ranges, side effects and potential toxicities.
• Payor knowledge, along with the ability to navigate Medicare, Medicaid and commercial insurance plans to assist with the intake benefit and authorization process.

Skills

• Skill and ability to effectively communicate.
• Proficient computer skills.
• Care of peripheral and central lines.

Abilities

• Ability to demonstrate personal motivation and initiative.
• Ability to troubleshoot problems that may arise in IV Therapy.
• Ability to follow appropriate infection control measures.
• Strong willingness to stay abreast of developments in the market related to infusion therapies.
• Ability to accurately and professionally document all records necessary to patient transition of care.
• Ability to communicate and work professionally and compassionately with varied audiences including patients, caregivers, patient families, physicians, nurses, hospital staff, and others involved in a patient’s care.

Core Competencies: All AVMC employees will effectively demonstrate these behaviors:

• Accountability
• Action Oriented.
• Client-driven.
• Compassion
• Effective Communication.
• Teamwork
• Ethics & Values.
• Integrity & Trust.

Education and Experience:

Education

• Associate degree in nursing from an accredited college or school of nursing.

Experience

• At least one (1) year of Case Management experience preferred.
• Experience in and knowledge of Home Health or, three (3) years clinical nursing experience in the acute care setting required.
• Two (2) to three (3) years IV related experience preferred.

Required Licensure and/or Certifications:

• Current licensure as an RN in California.
• Current BLS/BCLS certification.
• Maintains a valid California driver’s license.

AVMC Conduct/Compliance Expectations:

• Ability to adhere with AVMC Leaves of Absence Policy.
• Ability to adhere with AVMC Paid Time Off (PTO) Policy.
• Ability to adhere with AVMC Recording of Hours Worked Policy.
• Ability to adhere to the department dress code.
• Ability to organize work and establish priorities.
• Ability to expand on own initiative in performance of duties.
• Skill and ability to follow the telephone etiquette/standards.
• Conforms to AVMC Standards of Excellence
• Ability to function effectively under pressure and meet time parameters.
• Ability to communicate effectively while maintaining good working relationships with co-workers, managers, and other hospital staff.
• Ability to adhere to the normal standards of courtesy and conduct as defined under the rules of hospitality at AVMC.
• Ability to maintain the confidentiality of patient, hospital, and department information.
• Ability to adhere to safety rules and regulations.
• Safely and effectively uses all equipment necessary to perform duties.
• Ability to interpret and function under hospital and department policies and procedures.
• Conforms with required and appropriate Joint Commission requirements.
• Conforms with and supports hospital quality assurance and improvement guidelines.
• Ability to participate effectively in department and hospital staff education.
• Display a willingness to work as a collaborator.
• Ability to always give and support the highest level of patient/customer satisfaction.
• Supports and adheres to the values and mission statement established by the AVMC Board of Directors.
• Ability to demonstrate knowledge and understanding of Corporate Compliance rules and regulations, complies with duty to report behavior standard, demonstrates understanding of purpose for Corporate Compliance hotline and importance of seeking guidance from a supervisor when in doubt regarding a possible corporate compliance issue.

Key Physical Requirements and Working Conditions:

• Must meet job physical standards: vision, hearing, and manual dexterity, ability to walk and meet lifting requirements.
• Must be able to tolerate repetitive hand and arm movements.
• Able to walk to and from patient home and employee vehicle.
• Able to lift and/or carry up to 10 pounds.

A detailed description of the physical requirements of this job is maintained in the Employee Health Department.

Education and Experience:

Education

• Associate degree in nursing from an accredited college or school of nursing.

Experience

• At least one (1) year of Case Management experience preferred.
• Experience in and knowledge of Home Health or, three (3) years clinical nursing experience in the acute care setting required.
• Two (2) to three (3) years IV related experience preferred.

Required Licensure and/or Certifications:

• Current licensure as an RN in California.
• Current BLS/BCLS certification.
• Maintains a valid California driver’s license.