Care Transition Nurse - LPN (PRN)

Transitional Care Nurse

At FMOLHS, we offer you so much more than just a job in the healthcare industry. We offer career opportunities for people who have a calling to share their gifts and talents as part of our healing ministry. As a Catholic hospital, we are here to create a spirit of healing. We offer you something special - the chance to do God's work by helping to serve people in need throughout our community, every day.

Job Summary

The transitional care nurse works with members of the multidisciplinary team and the patient/caregiver to ensure that an effective and well-informed discharge occurs. The nurse will function as a liaison between the acute setting and sub-acute levels included, but not limited, to home health, nursing home, hospice care and/or family caregiver. The Transitional care nurse provides continued education post discharge to the patient/family members to promote positive outcomes and ensure understanding of disease, prevention and treatment modalities utilized. The nurse provides resources to the patient/caregiver necessary to meet the specific identified needs of the patient. The nurse collects, inputs and maintains specific data necessary for the completion of specific dashboards which are utilized to enhance and coordinate the needs of the population served. In conjunction with the RN coordinator, the Transition of Care nurse reviews and discusses findings/concerns in relationship to the established plan of care for further evaluation and assistance. The nurse is responsible to complete all NICHE GRN education and continue participating in geriatric nursing education programs to maintain knowledge base. The Transition nurse behaves in a professional manner, and consistently demonstrates and promotes the values of respect, honesty, care, and dignity for the patient and all members of the healthcare team. The Transition of Care nurse is committed to the constant pursuit of excellence in improving the health status of the population followed.

Responsibilities

1. Technical Tasks

• Collaborates with members of the multidisciplinary team to facilitate successful transitions to the home setting post discharge.
• Prioritizes follow up of the patient's care needs and referrals according to established criteria and levels.
• Provides appropriate referrals to sub-acute levels of care and physicians based on identified needs of the patient.
• Provides support and education to all patients/caregivers in disease management addressing critical issues and treatment. Evaluates the patient/family knowledge based on developmental needs and assessment of the specific population being addressed.
• Recognizes each of the following aspects of patient's condition: diagnosis, medications and support systems. Utilizes critical thinking skills in achieving successful outcomes related to disease/medication management. Responsible for assisting in the coordination of discharge planning including primary care/specialty follow-ups, clinic appointments and SBAR communication with referral agencies post discharge.
• Supports and promotes patient self-management and empowers patients/families to achieve maximum levels of wellness and independence.
• Communicates critical information related to risk issues or other need to know information with RN Coordinator, administration, risk management, medical management, medical staff and patient advocates.
• As a member of the multidisciplinary team, works to obtain resources for high-risk patients for readmission related to inadequate family support, poor understanding and social restrictions. Notifies and discusses findings and concerns with attending physicians and provides possible suggestions for additional support, i.e. Geriatric Medical Clinic, Transitional Care Clinic, Council of Aging, Elderly protection, etc.
• Documents interventions and encounters in a timely and thorough manner in appropriate areas of the chart.

2. Data/Measurements

• Collects and maintains specific databases on care transition population.
• Completes data input timely and accurately.
• Participates in measuring clinical outcomes and data procurement. Represents the care transition program on performance improvement teams as requested.

3. Collaboration and Partnership

• Consistently communicates/ collaborates with patients/caregivers and identified sub-acute providers to maximize patient outcomes.
• Communicates, collaborates with community resources to meet specific patient needs and to enhance patient outcomes.
• Maintains knowledge regarding program initiatives based on geriatric population/needs and incorporates the outcomes into practice.

4. Critical Thinking

• Appropriately utilizes LACE to determine the transition care needs of the patient.
• Identifies/consults available resources to meet patients' identified transition needs.
• Assists the patient/family/caregiver in the management of complex health issues to improve health outcomes utilizing education and available resources. Understands personal limitations and further assistance when needed in the care needs of the patient.
• Collaborates with all multidisciplinary team members to coordinate and assure continuity of care and assist in meeting the patient's individualized plan of care post discharge. Effectively communicates with community providers information and needs of the patient requiring further follow through with in the home environment.
• Provides ongoing support to patients following discharge, through telephone calls and assistance with community resources.
• Provides assistance with obtaining post-discharge a primary care provider and/or specialist based on patient's needs and financial limitations for continued long term care needs.
• Provides education to the patient and family/caregivers in medication self-management, use of a personal health record, knowledge of disease management and potential problems that may need further intervention.

5. Other duties as assigned

• Consistently performs 12 organizational Service Standards focused on Values, Service, and Quality.

Qualifications

• 3 years clinical experience.
• Graduated from a Practical Nursing School program.
• NICHE GRN Certification (required within six months)
• Proficient in English, verbal, written Communication and computer skills
• Current unrestricted Louisiana LPN license CPR Certification.

Franciscan Missionaries of Our Lady Health System