Transitional Care Nurse Program Coordinator



Posting Date January 21, 2021
Job Title Transitional Care Nurse Program Coordinator
Specialty RN
Hours FT
Overview Current opening: Monday - Friday; 37.50 hours per week, 8 a.m. - 4 p.m. Reporting to the Home Care Director, the Concord Regional VNA Transitional Care Nurse Program Coordinator assesses, plans, implements and evaluates the agency's transitional care nurse program. The coordinator provides clinical support, education and oversight of the transitional care nurse team. Develops relationships in the community to develop referral sources and coordinate care. The Coordinator will effectively interact with patients, caregivers and other healthcare team members while maintaining all standards of professional nursing. Provides direct patient care visits, including, but not limited to, medication reconciliation and admission visits. RNs will supervise Licensed Practical Nurses and Licensed Nursing Assistants assigned to patients. Essential Functions Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Provides direct patient care visits 75% of the time, including, but not limited to, medication reconciliation and admission visits. Participates in the development of administrative policies and guidelines related to the transitional care nurse program and staff. Participates in the development and implementation of the Institute of Healthcare Improvement Age Friendly Health Systems model into care delivery. Identifies and participates in transitional care nurse staff recruitment. Participates in interview process for staff inclusion into the program. Plans and implements orientation for transitional care nurses. Ensures that nursing staff are adequately prepared for care delivery. Responsible for patient identification and referral process to transitional care nurse program. Participate in competency program for transitional care nurse staff. Assist in developing and implementing plan of action to address any identified skill needs. Identifies educational needs of transitional care nurses, general home care and hospice staff, and plans continuing education. Reviews clinical documentation of transitional care nurse records and develops an action plan to address gaps identified. Participates in the development and implementation of quality improvement activities for the Transitional Care Program. Completes transitional care nurse visits and co-visits with transitional care nurse staff. Coordinates and facilitates routine case conferences with transitional care nurse team to discuss goals of care and progress and/or barriers to meeting goals Integrates the transitional care nurse team with community resources. Networks with local programs and providers to build positive professional relationships to enhance continuity of care and to promote home care. Provides community education on transitional care nurse program when requested. Develops and implements appropriate plan of care (POC) that complies with referral source orders, specific treatment measures, frequency/expected duration and discharge goals in partnership with the patient, healthcare provider, patient representative (if any) and/or caregiver(s) based on thorough assessment incorporating all aspects of patient limitations and goals, and potential discharge environment. Documents accurate and ongoing assessment/reassessment, treatment and discharge of the patient: nursing interventions, patient response to care provided, patient/caregiver educational needs, problems, capabilities, limitations and progress toward goals. Documentation includes evidence of appropriate patient/caregiver teaching, and the understanding of these instructions in accordance with agency guidelines. Engages the patient /caregiver in meaningful education as indicated per care plan. Communicates with all physicians involved in the POC and other health practitioners related to the current POC. Participates in interdisciplinary team, agency projects, committees, QAPI program and/or other activities upon request and approval from direct supervisor. Other Job Functions Supervise Licensed Practical Nurses and Licensed Nursing Assistants assigned to patients according to federal and state regulations. Coach, mentor and precept new nursing employees and students. Attends Agency In-service programs.
Qualifications Requirements Graduate of an accredited school of nursing, accompanied by current New Hampshire license, or compact state license through the Nurse Licensure Compact (NLC). One year of recent general medical/surgical or skilled/acute care nursing experience. Work Environment The employee will be exposed to a variety of uncontrolled work environments. The employee may be exposed to all kinds of weather conditions while driving to and from work assignments. The employee may also be exposed to blood and bodily fluids, virus, disease and infection from patients and environmental hazards in the work environment. The employee may be required to work extended periods of time using a laptop and/or other mobile device. Physical Demands The physical demands described here are representative of those that must be met by an employee to successfully perform the essential function of this job. While performing the duties of this job, the employee is regularly required to talk and hear. Specific abilities include reading, writing and speaking in English, normal or correctable vision with the ability to accurately discern colors, and hearing. This position requires the ability to use a computer to document patient care. Specific abilities include use of fine motor skills to type, write and perform professional skills. This position requires intermittent physical activity, including standing, walking, bending, kneeling, stooping and crouching as well as lifting and supporting patients. This position requires the ability to minimally lift up to 50 lbs. and the ability to provide up to 75% assistance for patient transfers. This position requires the ability to frequently enter and exit and/or sit in an automobile for prolonged periods while commuting to work assignments.
Agency / Location Concord Regional Visiting Nurse Association
30 Pillsbury Street
Concord, NH 03301
Contact Information Abigail Ofrias
Concord Regional VNA
30 Pillsbury Street
Concord, New Hampshire 03301
Phone: 6032305676
Fax:
Email: abigail.ofrias@crvna.org
Website: www.crvna.org
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