Transitions of Care Nurse - ECU - Full-Time

Signature HealthCARE is a family-based healthcare company that offers integrated services in 10 states across the continuum of care: skilled nursing, rehabilitation, assisted living, memory care, home health, cognitive care, and telemedicine.p. A growing number of our centers are earning quality assurance accreditation and pioneering person – directed care. Many of our skilled nursing facilities have achieved a 4 or 5-star overall rating from the Centers for Medicare & Medicaid Services. Additionally, we have been awarded as a certified Great Place to Work for three years in a row and Modern Healthcare’s “Best Places to Work!”

Signature Healthcare is a long-term healthcare provider that is committed to providing an environment of wellness, healing, and independence for its residents.

Summary:

Environment:

Essential Duties & Responsibilities:

Teamwork & Collaboration:

• Provide outstanding leadership to strengthen the organization’s ability to deliver superior quality medical services.
• Actively participates in the company’s Hub of Excellence teams and company’s initiatives.
• Provide feedback for the implementation and improvement of the Hub of Excellence model of care.
• Work collaboratively with hospital discharge teams, SHC Medical Partners and their clients’ staff to ensure coordinated Hub of Excellence activities.
• Maintain and develop relationships with all customers and key strategic partners.
• Meet physical and sensory requirements stated below, and be able to work in the described environment.
• Interprets and implements quality assurance standards.
• Develop, maintain and analyze various tracking documents to facilitate the communication of clinical operations.
• Compile and distribute reports, as needed.
• Attend required conference calls, webinars and education/training events.
• Other special projects and duties, as assigned.
• Report and escalate matters to executive management as needed.
• Travel to service locations as assigned.
  h4. Care Coordination:
• Serves as the contact point, advocate, and informational resource for patients, care team, family/caregiver(s), payers, and community resources.
• Performs transition of care assessment using questionnaire / assessments provided
• The TCN will coordinate the interdisciplinary care team meeting to maximize the involvement of interdisciplinary expertise, ensuring the appropriate professionals are involved, critical issues are addressed, treatment goals are understood and the care plan is executed correctly.
• Develop a Care Transition person-centered plan of care that includes patient’s personal goals.
• Works in collaboration with Hub providers to identify and address risk for readmission.
• Communicates the person-centered plan of care to all providers in all settings.
• Ensures Hub receives medical history from hospital records, PCP and/or nursing facility.
• Identifies and confirms services required for successful transition to home and facilitates referrals.
• Increase continuity of care by managing relationships with tertiary care providers, transition-in-care and referrals.
• Assist with the identifications of “high-risk” patients (the chronically ill and those with special health care needs), and add these to the patient registry.
• Cultivate and support Hub of Excellence team with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions-in-care and referrals.
• Monitor adherence to care plans, evaluate effectiveness, monitor patient progress in a timely manner and facilitate changes as needed.
• Create ongoing processes for patient and family/caregivers to determine and request the level of care coordination support they desire at any given point in time.
• Facilitate and attend meetings between patient, family/caregivers, care team, payers, and community resources, as needed.

Education:

• Serve as a health education resource for the Hub of Excellence and its client, patient and families.
• Use appropriate strategies and methods to facilitate health promotion and disease prevention.
• Implement and manage health educations strategies, interventions and programs.
• Translate scientific language and concepts into clear, simple and understandable information for patients and clients to maximize the potential for them to take reasonable action.
• Assess patient and client needs for health education, including change readiness.
• Help develop, identify, implement and improve patient education material and other tools that encourage healthy decisions.
• Coach patients to learn self-management skills in order to have successful home transitions and reduce readmissions.
• Coach patients to understand indicators (red flags) that signify his or her condition is worsening and coaches to be knowledgeable of how to respond.
• Communicates with the patient and family to make sure all needs are met.
• Connect patients to relevant community resources, with the goal of enhancing patient health and well-being, increasing patient satisfaction, and reducing health care costs.
• Educate patient and family/caregivers about relevant community resources.
• Develop an annual calendar of educational activities for (1) clients (2) patients (3) caregivers/families
• Identifies essential competencies of client staff and assures appropriate educational opportunities exist to promote the growth and development of staff.
• Maintains educational program attendance records.

Job Requirements:

• Bachelor’s degree in Nursing.
• Minimum of two (2) years’ experience as Registered Nurse, long-term care preferred.
• Strong clinical skills including an understanding of and ability to implement evidence based care.
• Understanding of the health care system and its components including sites of care, delivery models, and the roles of various providers and health care professionals.
• Experience in EHR along with workflow and practice management.
• Experience with healthcare operations and clinical workflows.
• High level of planning and implementation skills to successfully execute all necessary projects, group strategic initiatives, etc.
• Effective verbal and written English communication skills.
• Demonstrated intermediate to advanced skills in Microsoft Word, Excel, Power Point and Outlook, Internet and Intranet navigation.
• Highest level of professionalism with the ability to maintain confidentiality.
• Ability to communicate at all levels of organization and work well within a team environment in support of company objectives.
• Customer service oriented with the ability to work well under pressure.
• Strong attention to detail and accuracy, excellent organizational skills with ability to prioritize, coordinate and simultaneously maintain multiple projects with high level of quality and productivity.
• Strong analytical and problem solving skills.
• Ability to work with minimal supervision, take initiative and make independent decisions.
• Ability to deal with new tasks without the benefit of written procedures.
• Approachable, flexible and adaptable to change.
• Function independently, and have flexibility, personal integrity, and the ability to work effectively with stakeholders and clients.
• A valid driver’s license and reliable transportation for travel to multiple sites of service within the assigned area.

Physical and Sensory Requirements:

• Moderate physical activity:
  • Requires handling of average-weight objects up to twenty five (25) pounds.
  • Sitting for more than two (2) hours at a time.
  • Requires consistent computer work with repetitive typing and concentrating on computer screen.
  • Travel, including flying and/or driving, for more than one (1) hour at a time.