Responsible for assessing, planning, monitoring, and evaluating the designated patient?s plan of care in collaboration with the treating physician and nurse team to assist in determining the most appropriate transitional care needs. Transitional Care may include transitioning from the hospital to a number of traditional outpatient settings (home health, skilled nursing facilities, immediate next day) primary care follow up and more novel care options (in home visit by nurses, social workers, or advance practice providers.
Bachelor's degree in Nursing with two years' nursing experience in a clinical setting required. Experience in Emergency or Palliative Nursing Care preferred.
LICENSURE, CERTIFICATION, and/or REGISTRATION:
Registered Nurse licensure from the State of North Carolina Basic Cardiac Life Support (BCLS) required Advanced Cardiac Life Support (ACLS) required within 1 year of hire for Adult Critical Care, Adult ED Pediatric Advanced Life Support (PALS) required within 1 year of hire for Network ED, Peds ED, PICU and NICU, and other areas per unit guidelines
1. Utilizes the nursing process to provide patient- and family-centered care focusing on physical, emotional, spiritual, cultural, religious, and environmental needs. 2. Ensures quality family-centered patient care by adhering to the policies of WFBMC, involving patients and their families in identifying their needs, collaborating with team to create a plan to meet those needs, and effectively communicating the plan across the continuum of care. 3. Maintains a safe, therapeutic, and healing environment through ensuring patient privacy and responsive, respectful, accepting, and professional behavior. 4. Acts as a patient advocate throughout the continuum of care including all patient settings and in the community. Coordinates the effective and efficient delivery of patient care services through the application of care management principles. 5. Demonstrates ability to function in a professional practice model through active participation in shared governance, acceptance of personal responsibility for professional growth, exhibiting critical thinking behaviors, and demonstrating leadership and clinical excellence. Demonstrates responsibility for personal development by participating in continuing education offerings. Participates in peer review. 6. Utilizes targeted reports and screening tools to identify Emergency Department patients who will benefit from more intensive care navigation within the ED and post ED discharge. The frequency and intensity of care management will be determined by the patient?s needs. Provides care coordination that requires on-going communication with the Medical Center identified providers, primary care practice, CCNC care management staff, Managed Care Organizations, Department of Social Service, Health Department, Hospital, community providers (skilled nursing facilities, CarePlus at the Downtown Health Plaza) or others involved in providing care to the identified patients. 7. Ensures appropriate follow-up for identified patients who have recently been admitted and discharged from the hospital or Emergency Department. Works with a team of care transition professionals to ensure a home or office visit when appropriate within one business day of Emergency Department discharge, provides education about the navigation services the team will provide. 8. Understands the chronic disease process, evidence based treatment and management, with the ability to apply all in the care management services provided to the patient. 9. Functions as a team member with Emergency Department staff, Care Coordination, and inpatient nursing to transition patient to appropriate primary care and post-acute care setting. Communicates in collaboration with the entire spectrum of care surrounding a patient. 10. Knowledgeable of CMIS and WakeOne with the ability to enter/document patient information in both.
Strong oral and written communication skills Ability to provide direct and indirect patient care Ability to work collaboratively with all disciplines Ability to prioritize when multiple demands exist
Subject to highly stressful and crowded conditions Moderate noise environment Handles emergency or crisis situations Subject to many interruptions Secures absentee replacement on short notice Required to wear PPE
0% 35% 65% to to to 35% 65% 100% N/A Activity X Standing X Walking X Sitting X Bending X Reaching with arms X Finger and hand dexterity X Talking X Hearing X Seeing Lifting, carrying, pushing and or pulling: X 20 lbs. maximum X 50 lbs. maximum X 100 lbs. maximum
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