RN Transitional Care Coordinator - Case Management
Partners with multidisciplinary teams, both inpatient and community centered, to provide evidenced based education, resources and post discharge telephonic support for chronically ill patients. Consistent application of these efforts should lead to optimization of health outcomes for patients and reduction of length of stay/hospital readmissions for this patient population.
Develops and recommends protocols and guidelines for best practice treatment of patients with chronic health conditions across the continuum of care.
Coordinates with outpatient resources, as needed, to ensure implementation of chronic disease management services at discharge.
Collaborates with the hospital care team, outpatient care team, and community agencies as needed to creatively resolve issues that could prevent safe and timely patient discharges.
Assesses patient /family for educational needs, taking into account health literacy issues and/or language barriers to ensure appropriate learning.
Utilizes motivational interviewing techniques to empower patients/families to understand their disease process, options and lifestyles changes.
Provides patient centered education focused on signs/symptoms of disease process, medications, patient responsibilities post discharge and ensures patient/caregiver ability to “teach back “information shared.
Participates in root cause analysis on patients readmitted within a 30 day window to gain insight into additional patient needs in managing their disease process in the community.
Provides telephonic support with 24-72 hours after discharge to ensure discharge plan implemented is effective. Addresses any gaps in care identified during this call and documents in EMR.
Partners with assigned RN case manager/social worker and bedside RN and shares information gained in interview/education which could impact care and safe / timely discharge.
Consults appropriate providers as needed.
Evaluates transitional care team processes to drive change that ensure efficiency and maximize benefit to the patient and organization.
Performs related duties as assigned.
EDUCATION: Bachelor’s Degree in Nursing.
EXPERIENCE: Three (3) years of combined experience in teaching in a healthcare setting and in an acute care environment.
LICENSURE OR CERTIFICATION: Current RN licensure permitting work in State of Arizona, and Basic Life Support (BLS) certification.
KNOWLEDGE, SKILLS AND ABILITIES:
Strong critical thinking skills related to medications, physiology and chronic disease processes.
Skill in the use of computer programs, especially Word, Excel, Outlook, and PowerPoint.
Ability to interact with patients, colleagues and physicians in a thoughtful and professional manner.
Ability to complete routine reports and correspondence.
Ability to listen and accurately interpret others’ communication or instructions to take appropriate action.
Ability to speak and communicate effectively in person or via email.
Ability to define a problem collect/analyze data, and draws valid /supported conclusions.
Ability to manage projects and multi-task as needed.
Ability to independently follow through on assignments and action plans.