Job Description:

Employment Type:Full time
Shift:





Description:

Position Purpose:


The Transitional Care Nurse is an integral part of improving the coordination of care for patients between the acute care setting and community setting. The purpose and goal of a transitional care nurse is to assess, manage, and coordinate patient health care needs following their transition from the hospital setting to home with an aim to reduce risk for readmission, improve health outcomes, and increase patient satisfaction. The Transitional Care Nurse assists the patient in achieving their highest level of wellness, provides coaching for self-management in both recovery and learning to live with chronic illness, and acts as an advocate. The Transitional Care Nurse assesses needs, develops individualized care plans, coordinates services, collaborates with interprofessional patients of the care team, facilitates access to resources, monitors and evaluates outcomes, and documents such interventions appropriately within the legal medical record.



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Manages transitions of care when patient transitions from one setting to another. Completes timely post-hospital/facility follow-up: medication review, follow-up appointments, assess symptoms, teach warning signs, review discharge instructions, coordination of care, and problem solve barriers.


Conduct root cause analysis for patients readmitted within 30 days post hospital discharge to identify gaps in care.


Collaborates with appropriate providers, external healthcare organizations throughout the continuum of care and communicates with an interdisciplinary team to develop and maintain positive working relationships while providing for the diverse needs of patients and families.


Functions as a coordinator and manager of a defined health population, with modifiable risks, across multiple care settings and for multiple physicians/health care providers or health plan counterparts.


Integrates evidence-based clinical guidelines, preventive guidelines, and protocols in the development of individualized care plans that are patient-centric, promoting quality and efficiency in the delivery of health care. Continually monitors patient/family response to plan of care and revises the care plan as indicated.


Provides self-management support with a focus on empowering the patient/family to build capacity for self- care.


Fosters a team approach and includes patient/family as active patients of the team. Takes the lead in ensuring continuity of care extends beyond ambulatory practice boundaries.


Supports the activities of identifying and evaluating patients' needs inclusive of transition care planning and readmission prevention, in collaboration with the interdisciplinary team.


Follows nursing process and implements systems of care that facilitate care coordination. Aligns care management services to the needs of the population. Provides education and health coaching and engages patients using motivational interviewing skills.


Serves in an expanded healthcare role to collaborate with all interprofessional colleagues, and patients /families to ensure the delivery of quality, efficient, and cost-effective health care services.


Stays abreast of evidence, existing and emerging strategies regarding effective engagement and communication techniques, care management models and tactics, and behavior change tools and incorporate knowledge into clinical practice.


Perform psycho-social assessment, identify patients in need of behavioral health support and refer as appropriate.


Conduct social needs assessment to identify patients in need of community resources and refer as appropriate.



SKILLS, KNOWLEDGE, EDUCATION AND EXPERIENCE:

• RN licensure required in the State of Florida.


• Associate Degree in Nursing required; BSN preferred.


• 5+ years of experience in a healthcare environment. Experience with adult medicine in primary care/ambulatory care, ED, critical care, or hospital medical-surgical setting, including health plans or post-acute care such as home health agency. Care/Case management experience preferred.

• Knowledge of chronic conditions, evidence-based guidelines, prevention, wellness, heal


• Exhibits an outcome and continuous quality improvement focus with the ability to interpret and synthesize data.


• Demonstrates ability to work autonomously and practice effectively in a fluid, dynamic, and rapidly changing environment.


• Displays excellent assessment and triage skills. Ability to integrate evidence into clinical practice.


• Develops positive relationships and sets appropriate boundaries with patients/families.


• Demonstrates proficiency in use of computer and other applicable technology.


• Experience with Epic Healthy Planet preferred.


• Basic Life Support (BLS) for the Healthcare Provider certified or obtained by the end of the orientation period.


• Knowledge of confidentiality, legal, and liability practices.


• Ability to work effectively and collaboratively with multiple healthcare disciplines.

Our Commitment to Diversity and Inclusion



Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law. Apply Now