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Job Title:Transition Nurse Navigator - Heart Failure Program

Department:Ross | Heart Failure Transitions of Care

Scope of Position/Position Summary:
The Heart Failure (HF) Program Care Navigation Liaison improves outcomes by reducing all cause readmissions and coordinating episodes of care among patients in a defined population or disease process. The primary focus is on the coordination and delivery of efficient, effective, compassionate, patient centered care and safe transitions across the care continuum. The HF Program Care Navigation Liaison monitors the patient care process and physiological needs; educates, documents, communicates, and collects data to evaluate and assure patient/family readiness for discharge. The HF Program Care Navigation Liaison facilitates the lateral integration of the care team, collaborating with physicians, nurses and other staff across the continuum to provide comprehensive disease management, assessment, treatment, education, and follow-up evaluation for patients; and, to communicate the plan of care in coordination with post acute care settings. The HF Program Care Navigation Liaison ensure a fluid integration of all willing patients discharging with a primary diagnosis of HF and are followed for Care Navigation services in the Ambulatory space Serves as a liaison with post-acute partners including, but not limited to, CVS, Wellsky, and others as determined by the HF Leadership team

Duties and Responsibilities
Liaison/Care Coordination: 50% of time
• Serves as a liaison to ensure enrollment of appropriate HF patients with post-acute partner organizations
• Communicates with post-acute partners on HF patient care plans as needed
• Coordinates the evaluation process of the HF patient population. May complete and document portions of the evaluation process, collaborating with other team members to ensure completion of all required information.
• Is a liaison between the medical team, staff nurses, consult teams, ancillary staff, Ambulatory Care Navigation services, PCP, and patients. *Coordinates ancillary consults, suggests possible patient needs including, for example, PT, OT, cardiac rehab, palliative care, and social services.
• Reviews medical team documentation and consults as a basis for intervention
• Develops and manages processes related to pre-admission and post-discharge care transitions
• Establishes relationships/clinical pathways with providers/agencies to optimize care for defined patient population
• If patient is identified in Acute Care setting as high risk, may perform or consult for face-to-face assessment of patient; if a readmission, RN collaborates with IP Case Manager and conducts a patient interview to review possible causes
• May participate in Attending Rounds to fully understand plan of care, provide decision support and focus team on expected course of disease management
• Develops and proactively consults for or modifies a care plan with the medical team for each patient by assessing educational needs in conjunction with caregivers; communicates plan to patient and facilitates patient adherence
• Interacts with consulting physicians, HF Program Lead APP, and other health care providers internally and externally to assure the progression of plan of care and externally to facilitate follow-up care
• Consults for and acts as Liaison with Multidisciplinary Care Conferences including ethics discussions, develops concise patient care plan for use by the team, and documents recommendations made utilizing standardized care protocols in accordance with nationally recognized care guidelines; provides information about past hospitalizations and known contributing factors to readmission
• Collaborates with and assists case managers in discharge planning, identifying outpatient needs and follow up care, and arranging for discharge prescriptions
• Manages patient progress post-discharge by ensuring patient follow-up appointments, tests, and procedures are noted in the After Visit Summery (AVS).
• For patients requiring additional Care Navigation services beyond the first 30 days post-discharge, contacts patients within an established timeframe and at designated intervals to assess patient status, answer questions, provide education, and facilitate communication with physician as indicated.
• Serves as a clinical point person for outpatient phone calls regarding symptom management, post acute care and follow up. Escalates level of services provided if patient’s condition worsens post discharge.
• Using established criteria, may make home visits to patients or post-acute facilities to determine adherence to discharge instructions including medication management and keeping appointments; assesses the appropriateness of the post-acute setting, adherence to the care plan, transportation and support system needs and responds accordingly.
• Communicates, verbally and in written form, with referring physicians, primary care physicians, home care agencies, ambulatory care navigation teams, and post-acute facilities when applicable
• Displays thorough and accurate documentation of all communications throughout the episode of care.
• Works in conjunction with the HF Program Lead APP to ensure all HF Patients are provided an opportunity to enter the HF Care Program
• Brainstorm and develop efficiency opportunities for the team and patients regarding education, process improvement, and quality improvement

Education: 20% of time
• Forms a working relationship with patients and families to educate regarding disease specific needs and available resources
• Introduces and engages patient in post-acute services provided by the HF Care Team and re-enforces education provided by bed-side nursing regarding HF care when possible
• Assures patient/family understanding of their diagnosis, treatment options, and available resources
• Develops patient education programs and tools; standardizes content and delivery
• Responsible for outreach efforts with home care agencies, skilled nursing facilities, LTACHs, and other community agencies to provide disease specific education
• Mentors new navigators
Quality Improvement: 25% of time
• Participates in administrative meetings, task forces, committees, and projects with disease process focus
• Maintains patient tracking tool and discharge database for all patient encounters.
• Articulates within the disease management specialty and maintains current knowledge of literature,
research and national guidelines; assists with disease specific program improvement projects
• Participates in readmission and other related projects as indicated
• Maintains an awareness of Medicare Conditions of Participation related to discharge planning
Other Duties as Assigned: 5% of time

Minimum Qualifications:
For Hire – Registered Nurse and BSN required, Masters preferred. Five years of recent clinical experience applicable to the population preferred; knowledge of evidenced-based practice and disease specific processes; knowledge of technology and payer protocols desired. Case management and post-acute care experience (home care, SNF, LTACH) experience desirable.

Additional Information:

Location:Ross Heart Hospital (0353)

Position Type:Regular

Scheduled Hours:40

Shift:First Shift

Final candidates are subject to successful completion of a background check. A drug screen or physical may be required during the post offer process.

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