Nurse- Lung Transplant BWH

Lung Transplant Nurse Coordinator

Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.

The Lung Transplant Nurse Coordinator is a professional registered nurse licensed in the state of Massachusetts with transplant experience who is responsible for all aspects of ambulatory and in-hospital care of the pre-transplant, inpatient and post-transplant patient. This position will focus on the pre-transplant patient, but will also work closely with all members of the transplant team, inpatient staff, and others as necessary to ensure efficacious care during the transition between pre-, peri-, and post-transplant phases in ambulatory and hospital settings. Additional responsibilities will include collecting and entering data into EPIC and transplant regulatory databases as required by the hospital, the transplant service line, and by local, regional and national agencies.

Transplant patients are an extremely complex group of patients and as such the transplant coordinator must possess a strong clinical background. This nurse must be organized, they must pay attention to detail, demonstrate the ability to coordinate and follow through on all aspects of the patient's care and effectively communicate with all members of the transplant team, the patient / family and transplant unit. The coordinator needs to be self motivated to complete all necessary patient care responsibilities in a timely manner. The transplant coordinator will need to demonstrate the ability to effectively manage patients by assuming full responsibility for assessment, planning, implementation and evaluation of patient care. The RN is directly responsible to a designated nurse manager, director, or supervisor. The transplant coordinator will work on site at the BWH Main campus, and at any off-site locations in Massachusetts and surrounding states, as needed and directed by leadership. Therefore, this candidate may need to obtain necessary nurse licensure in other states.

Organization of Patient Care:

• Reviews referral documentation and medical records and regularly meets with the Program Directors to identify potential transplant patients. Contacts referring physician practices to determine current status of patient and provide ongoing updates. Coordinates pre-transplant evaluation with primary care providers.
• Collaborates with all members of the transplant team for seamless coordination of newly referred patients for lung transplant evaluation.
• Coordinates and facilitates New Patient and Pre-Transplant clinic sessions. Works with providers to ensure completion of necessary testing at appropriate stages of evaluation.
• Participates in the longitudinal informed consent process with patients in the consultative and evaluative phases of lung transplantation. Ensures provision of patient education materials, reviews key elements of the education process, including risks, benefits of transplant, the evaluation procedure, risks of immune suppressing medication, alternative treatment options, and other elements of the informed consent process. Ensures completion of all documentation as pertains to informed consent.
• Facilitates completion of the evaluation for lung transplant candidacy. Ensures multi-disciplinary participation in the pre-transplant phase of transplant per protocols and policies. Reviews evaluation testing and identifies outstanding items. Works with administrative coordinator and referring physician to coordinate testing for presentation at multidisciplinary team meeting for discussion of candidacy.
• Compiles and summarizes evaluation results for presentation at multidisciplinary team meeting utilizing Epic and regulatory databases. Documents results of discussion at Multi-Disciplinary Selection Committee Meeting. Completes all required documentation related to determination of candidacy. Communicates with patient and referring physician regarding recommendations of the Multi-Disciplinary Selection Committee.
• Facilitates and coordinates educational programs for patients in the consultative and evaluative phases of transplant. Provides education for the patient and family as needed, utilizing appropriate resources. Reviews, revises, and initiates development of patient teaching materials with other team members.
• Works closely with and collaborates on the workflow of the Pre-Transplant Administrative Coordinator to facilitate the care of patients in the consultative, evaluative, and wait list phases of the lung transplant process.
• Works with financial coordinator to provide medical information as requested by third party payers.
• Works with financial coordinator, social work, and other means of assistance as needed.
• Communicates patient information to the care team via appropriate documentation and team conferences.
• Conducts post acute patient follow-up to ensure execution of follow-up care, non-acute plan of care optimal service utilization and quality of care and service to patient pre and post transplant.
• Manages and continually improves systems to provide information on patients current level of care/changes in clinical status to Lung Transplant Team, referring physicians, financial coordinator/third party payers, UNOS and others.
• Works with Physicians Directors to review, revise, and initiate changes to improve the pre-transplant management process.

Quality of Care:

• Participates in multidisciplinary patient care conference and medical management meetings.
• Documentation is clear, complete, concise, and organized in its presentation, demonstrating skill in the nursing process.
• Observes principles of infection control in nursing practice, demonstrating awareness of potential/actual risks of infection and modes of transmission.
• Assists with preparation of reports/data for utilization of services review, QM activities, UNOS and Center of Excellence contracts.
• Participates with all assigned QAPI processes as directed.
• Participates with all assigned e-care improvement initiatives as directed.
• Seeks ongoing feedback to ensure nursing practice remains at the highest level.

Support and Extension of Clinical Activities:

• Coordinates out-patient care of pre lung transplant patients, including participation in multidisciplinary rounds, documentation of assessment and plan in the medical record, organizational efficiency and discharge planning and follow-up.
• Facilitates interactions of the multidisciplinary team members, including physicians, social work, transplant pharmacist, nutritionist and outside consultants.
• Acts as a liaison between members of the inpatient care team and outpatient management team, including heart transplant nurse practitioners.
• Communicates with referring physician team to keep them up-to-date regarding patients clinical status.
• Telephone contact with patients to assess clinical status, monitor response to therapy, adjust medications in consultation with clinical providers, and organize outpatient or inpatient follow-up as needed.
• Assists in urgent patient triage, including emergency room visits and transfer from outside institutions, and documents care provided.
• Provides education to transplant patients and family members regarding important aspects of care, including but not limited to evaluation, waitlist, peri transplant, activity, diet, medication adherence and healthcare follow-up. Helps to maintain current supply of patient/family education materials.
• Sets up consults with specialty providers, follows up consult recommendations and communicates results to patient and other providers.
• Assists with communication and correspondence to/from patients, employers, pharmacies and insurance providers with regards to medication prescriptions, cardiac rehabilitation, disability, family medical leave, and payment coverage. May also communicate and correspond with other providers (e.g., utility company, telephone company) as dictated by patient needs. These duties may require telephone calls, faxes, mail and/or e-mail.
• Meets regularly with medical program director and nurse practitioners to facilitate quality and process improvement initiatives. As requested, implements and assesses initiatives and summarizes results for team.
• Attends weekly clinical meetings and lung transplant clinics as needed.
• Works with financial counselor and social work to assist patients/families in need of financial support, insurance coverage, medications, housing and/or utilities.
• Cross trains to assist in covering for the in-patient nurse coordinator and post-heart transplant nurse coordinators.
• Ability to work on-campus wearing appropriate PPE when caring for patients requiring enhanced precautions.
• Ability to triage and manage high patient volumes with complex needs in a crisp and pithy manner.
• Other duties as needed and assigned by nursing, director, and transplant leadership.

Data Activities:

• Collects demographic and clinical data from hospital computer system, administrative sources, charts and weekly conferences and enters data into heart transplant databases as needed, including the United Network for Organ Sharing (UNOS) system.
• Provides research nurses with clinical data on subjects enrolled in research studies.
• May be asked to assist in writing summaries for administrative or clinical purposes as requested by the Nurse Manager, Nurse Director, or Medical Director of the Lung Transplant Program.

Professional Attribute:

• Establishes effective professional relationships with other members of the healthcare team.
• Establishes effective professional relationships with patients, families, and referring providers.
• Serves as role model and resource for other staff, providing assistance with the care coordination process, clinical skills and patient teaching.
• Maintains communication with other transplant units programs