Nurse Navigator - Dept of Medicine Center for Transitional Care

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Job description

Description

Job Schedule: Full Time
Standard Hours: 40
Job Shift: Shift 1
Shift Details:

Work where every moment matters.

Every day, almost 30,000 Hartford HealthCare employees come to work with one thing in common: Pride in what we do, knowing every moment matters here. We invite you to become part of Connecticut's most comprehensive healthcare network.

Hartford Hospital is one of the largest and most respected teaching hospitals in New England. We are a Level 1 Trauma Center that provides cutting-edge treatment to its patients. This is made possible by being home to the largest robotic surgery center in the Northeast and the Center for Education, Simulation, and Innovation (CESI), one of the most advanced medical simulation training centers in the world. When hospitals cannot provide the advanced care, expertise, and new treatment options for their patients require, they turn to us.

The Center for Transitional Care is located at 79 Retreat Ave. on the second floor of the Brownstone Specialty Clinic Building. This clinic was developed to reduce readmissions and prevent gaps in care in addition to reducing adverse outcomes to the patients leaving Hartford Hospital without a Primary Care Provider. A Nurse Navigator performs transitional outreach after hospital discharge and the clinic staff supports the patients for the 30-day post-hospital discharge in connecting with Specialty and Primary care.

Job Summary:

Functioning within the context of the framework for professional nursing practice, the Transitional Care Nurse Navigator is a registered nurse experienced in patient throughput, preventing transitional care gaps, and resolving issues to enhance the quality and continuity of a patient's or population health care leading to improved health outcomes and equitable care. This role supports the HHC mission to improve the health and healing of all.

Job Responsibilities:

• Functions as a member of an inter-professional care team in an expanded nurse role to help those patients without a primary care provider transition from the acute care setting ( HH ED or inpatient). The goals include reducing all-cause readmissions, and inappropriate ED utilization, improving care coordination for patients during the transitional care period, and ultimately improving care quality and access for vulnerable populations. This role will be responsible for educating the HH community at large and advocating for resources to enhance patient healthcare engagement and expand the collaboration and communication between (inpatient/ambulatory/outpatient/attending/transitional care/specialty care/primary care) providers and care teams for high risk/complex patients.

• Partners with the inpatient (i.e. acute care, IOL, STR) or ED physician and care team to proactively identify potential transitional care gaps for this patient population, and establish a safe transition plan. Key strategies include ensuring a patient/caregiver agreed upon Center for Transitional Care/Transition Clinic and urgent specialists scheduled appointment(s) with transportation, verifying patient has necessary DME, finalizing an achievable community medication plan, completing diagnostic workup, educating the patient on disease and symptom management, and incorporating a patient-centered home care plan.

• Performs post-hospitalization/ED transitional care interventions within 24-48 business hours after discharge, including post-discharge phone calls, patient education, symptom management, and medication reconciliation, and collaborates with transition clinic physician and (clinic and community) care team to minimize identified gaps in care.

• Throughout the post-inpatient/ED transitional care period, facilitates the completion of the diagnostic workup, follows up on unresulted diagnostics, collaborates with homecare, pharmacy, and DME to ensure the patient has necessary supplies/medications/resources, obtains necessary authorizations, and schedules additional consultant appointments.

• Collaborates with clinic physicians to resolve issues and to advance the treatment plan until the patient has an established primary care provider.

• In collaboration with the Transition Clinic physician, assists the patient in identifying a primary care practice for continued care and facilitates the transfer of care to that practice

• Documents all communication, transition plan, implemented strategies, and patient outcomes in EPIC.

• As a member of the Center for Transitional Care/Transition Clinic completes transitional care strategies and actions per CMS/Payer guidelines for Transitional Care Management or other program directives.

• Establishes a therapeutic rapport with patients and demonstrates a commitment to serve as a patient advocate.

• Demonstrates the ability to work independently as well as collaboratively as a member of the health care team in order to provide safe patient care and prompt and efficient service. The Transitional Care Nurse Navigator provides transitional care strategies to his/her peers/colleagues and patients based on need/coverage.
• Due to the nature of this busy outpatient clinic, the ability to multitask, along with outstanding communication skills and reliable follow up is required.

• Attends/Leads and actively participates in care team meetings to facilitate a safe transition plan or resolve a patient issue.

• Establishes evidence-based standard work and workflows. Develops and implements processes that improve the patient experience. Collects and analyzes patient and program level data identifies areas of opportunity, recommends improvements/revisions or program development, and leads/participates in the idea/plan implementation.

• Applies the nursing process as appropriate within the context of the organization's framework for professional nursing practice and following guidelines established by the team.

Qualifications

• Bachelor's Degree required; MSN preferred
• Minimum five (5) years of nursing experience, Inpatient and Ambulatory nursing experience
• Current Connecticut Nursing License
• BLS Certification
• Spanish speaking (verbal and written) is strongly preferred

We take great care of careers.

With locations around the state, Hartford HealthCare offers exciting opportunities for career development and growth. Here, you are part of an organization on the cutting edge - helping to bring new technologies, breakthrough treatments and community education to countless men, women and children. We know that a thriving organization starts with thriving employees we provide a competitive benefits program designed to ensure work/life balance. Every moment matters. And this is your moment.

As an Equal Opportunity Employer/Affirmative Action employer, the organization will not discriminate in its employment practices due to an applicant's race, color, religion, sex, sexual orientation, gender identity, national origin, and veteran or disability status.

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