Responsible for the assessment and coordination of patient care for the achievement of patient outcomes. Assesses, plans, implements, evaluates and coordinates patient care needs to facilitate the plan of care and timely discharge. Provides leadership for clinical coordination, staff development and collaboration among multidisciplinary caregivers.
Completes assessment of patient's clinical course to provide ongoing patient care coordination, verify patient's need for acute hospital level of care and identify discharge planning needs. Assesses patient/family adaptation to illness/disability and capacity to provide for patient's care needs. Identifies obstacles to discharge.
Collaborates with physicians, nurses, and other disciplines involved with care of the patient to foster a coordinated approach to patient care. Responsible for communicating with physician regarding the medical plan of care, anticipated discharge, and consideration of alternative setting. Facilitates and impacts process issues to avoid delays in patient care.
Collaborates with UM nurse to assess patient's clinical course and verify need for acute hospital level of care or medical stability for care at the next level.
Intervenes with appropriate individuals/department regarding delays in service that may have an impact on quality of care and/or length of stay. Collaborates with UM nurse to identify factors contributing to delays in service or delayed discharge. Report findings to Director of Clinical of Care Management.
Prepare patients and families for transition from hospital to home or alternative setting. Involve patients in their discharge planning to encourage independence. Involve family in care while pt in hospital to create realistic expectations for post-hospital care. Assure appropriate teaching is started.
Provide feedback to unit management regarding delays in patient care services.
Maintains clear and concise documentation in each patient record to reflect physical and functional limitations, psychosocial characteristics, educational needs of patient & family, family/social support systems, financial, economic, and discharge needs. Initiates referrals to disciplines as indicated. Documentation will reflect plan of care to address post-hospital care needs and evidence of patient/family involvement in planning.
Develops and arranges discharge plans for patients discharged to home with home health, Hospice, home infusion and routine sub-acute and skilled nursing facility placements and completes all necessary paperwork. Refers patients with complex discharge or psychosocial needs to Social Work.
Communicates with Placement Specialists to ensure safe and appropriate transfers to lower levels of care. (Assisted Living, subacute, snfs etc)
Participates in nursing unit and department clinical outcome projects as well as process improvement initiatives of care management.
Seeks peer and director consultation regarding problematic cases or cases demonstrating deviations from the plan of care.
Demonstrates commitment to work partners to help each other reach mutual goals and learn from each other. Demonstrates actions and behaviors that consistently promote trust, respect , a positive attitude and promote team morale.
Required Experience: Previous home health, case management, or discharge planning experience.
Excellent clinical knowledge and skills, strong communication, interpersonal, organization and leadership skills. Three to five years of staff nursing experience in appropriate nursing specialty. One year demonstrated leadership ability.
Medium work: Exerting up to 50 pounds of force occasionally, and/or up to 20 pounds of force frequently, and/or up to 20 pounds of force to constantly to move objects.
Required - Registered Nurse