Qualifications: An Advanced Practiced Nurse, Master or Doctorate Degree level RN who holds national certification in area of applicable expertise (has 6 months to obtain), with strong clinical and critical thinking skills, as well as excellent communication skills. The Transitional Care Coordinator will be knowledgeable in chronic disease management. He or she must be a true team player capable of and willing to support each team member in overall goal achievement of customer satisfaction and positive resident / patient outcomes.
Goals: The Transitional Care Coordinator will be a driving force to ensure patient transitions are as smooth and as safe a process as possible, thus driving positive clinical outcomes, patient, family and physician satisfaction and preventing avoidable readmissions to hospitals. Patients identified as high risk for hospital readmission will be a priority focus. The Transitional Care Coordinator will build key hospital and community relationships and will provide clinical guidance to support unit mangers and staff nurses.
Organizational: Reports to Hackensack Meridian Quality Care Management’s Chief Nurse Executive. Delegates to Care Mangers, Unit Mangers, staff nurses, certified nurse aides and unit secretaries. Collaborating clinical agreement is with the facility Medical Director.
- Evaluation of each new admission for diagnosis, medications, and stratifies risk for readmission to hospital utilizing the evidence- based LACE tool. Contributes to the plan of care, as appropriate, to ensure completeness, appropriateness and to clarify any issues.
- High risk patient’s clinical progress will be tracked to ensure care planning and physician’s orders are implemented.
- Develops collaborative professional relationships and communication handoffs and updates to coordinate care for high risk chronic disease patients (Eg. Heart failure care coordination across the continuum).
- Ensures appropriate interdisciplinary collaborative discharge planning, education and coordination of service needs are being met on each high risk patient to provide a safe transition to home and prevent a hospital readmission.
- Develops ongoing positive, collaborative relationships with key customers: physicians, hospital leaders, care managers, social workers, home care etc. including committee membership when appropriate and collaboratively agreed upon with Meridian Quality Care Management.
- Rounds with attending physicians whenever feasible on all high-risk patients.
- Attends high risk patient and family care conferences as needed.
- Monitors and follows up with patients on post discharge phone call clinical issues as needed.
- Attends Readmission Process Review Meetings, providing critical analysis to help team members identify issues and improve processes.
- Collaborates with Home Care team, providing guidance regarding clinical status.
- Attends Rehab rounds, providing guidance regarding clinical status.
- Assists the social worker with high risk patient’s discharge planning as it relates to the continuum of care and clinical resources available in the community.
- Contributes to nursing communication handoffs and documentation standards: 24 hour report, initial admission, weekly and monthly summaries, progress notes, care plan updates etc.
- Policy and Procedures will be followed and upheld.
- Provides oversight of chronic disease programs and related projects as requested by Director of Nursing in collaboration with Hackensack Meridian Quality Care. (eg. CHF program & COPD Program).
- Provides job related reports and audits as requested by Director of Nursing in collaboration with Hackensack Meridian Quality Care.
- Follows standard of care and clinical guidelines by keeping current with nursing literature and publications, seminar attendance, professional organization membership, networking and with Federal and State regulatory guidelines.
- Provides facility resident/patient “change of condition” and “urgent care” visits as appropriate (eg. within guideline of collaborative joint protocol agreement with facility Medical Director if applicable) to ensure early, timely interventions to prevent patient deterioration and preventable hospital readmissions.
- Has a basic working knowledge of State and Federal regulation requirements as they relate to LTC and subacute resident care.
- Ensures quality of care and customer satisfaction by providing necessary team support when needed communicating any team member issues that compromise patient care and satisfaction to the Director of the Nursing promptly.
Education, Knowledge, Skills and Abilities Required: Education, Knowledge, Skills and Abilities Preferred: Licenses and Certifications Required: Licenses and Certifications Preferred:
As a courtesy to assist you in your job search, we would like to send your resume to other areas of our Hackensack Meridian Health network who may have current openings that fit your skills and experience.