LPN/RN Nurse Navigator

The Nurse Navigator is responsible for providing timely clinical assessment, intervention, and care coordination for nursing-home residents experiencing a change in condition. The primary goal of this position is to identify and manage potentially avoidable changes in condition in the facility when clinically appropriate , while ensuring residents who require emergency or hospital-level care are transferred without delay.

The Nurse Navigator works closely with the Director of Nursing, nursing staff, attending providers, medical director, residents and families, EMS, hospitals, pharmacies, and other healthcare professionals to improve resident outcomes and reduce avoidable hospital transfers and readmissions.

Essential Responsibilities

• Serve as the clinical triage resource for acute changes in residents' conditions.
• Perform focused and comprehensive nursing assessments based on the resident's presentation and clinical needs.
• Identify early signs of deterioration and initiate appropriate nursing interventions.
• Review vital signs, laboratory results, medications, treatment records, recent hospitalizations, and changes from the resident's baseline.
• Notify the physician, nurse practitioner, physician assistant, or other appropriate provider promptly when a resident's condition changes.
• Use evidence-based clinical pathways to determine whether a resident may safely be evaluated and treated in the facility or requires transfer to a higher level of care.
• Recognize and immediately escalate emergency conditions, including suspected stroke, acute myocardial infarction, severe respiratory distress, significant bleeding, sepsis, serious injury, and other life-threatening conditions.
• Coordinate timely provider evaluation and treatment within the facility when clinically appropriate.
• Facilitate communication between nursing staff, providers, residents, responsible parties, EMS, and hospitals.
• Participate in preventing avoidable emergency department visits and hospital admissions while never delaying medically necessary transfer .
• Follow up on residents after hospital discharge to identify risks for return to the hospital.
• Coordinate post-hospital monitoring, medication reconciliation, follow-up appointments, laboratory testing, and treatment orders.
• Review hospital discharge summaries and identify discrepancies, missed follow-up needs, or changes in the plan of care.
• Participate in root-cause analysis of hospital transfers and readmissions.
• Identify trends and recurring clinical issues contributing to hospital utilization.
• Educate nursing staff regarding early recognition of changes in condition, appropriate escalation, and interventions that may be performed in the facility.
• Promote use of standardized communication tools such as SBAR and change-in-condition reporting.
• Assist with development and implementation of individualized care plans for residents at high risk for hospitalization.
• Participate in QAPI activities related to hospital transfers, readmissions, falls, infections, dehydration, respiratory conditions, CHF, wounds, and other high-risk conditions.
• Maintain accurate, timely, and clinically appropriate documentation.
• Protect resident rights, dignity, privacy, and confidentiality at all times.
• Follow Florida nursing laws and regulations, facility policies, federal requirements, and applicable standards of practice.

High-Risk Conditions to Monitor

Particular attention should be given to residents with:

• Respiratory infections and pneumonia
• COPD and respiratory exacerbations
• CHF and fluid overload
• Dehydration
• Suspected urinary or other infections
• Falls and injuries
• Altered mental status
• Diabetes and abnormal blood glucose
• Wounds and cellulitis
• Medication-related problems
• Poor oral intake or functional decline
• Recent hospital discharge or previous hospital transfer

Hospital Transfer Reduction Responsibilities

The Nurse Navigator will maintain a hospital-transfer reduction focus by:

• Reviewing every potentially preventable hospital transfer.
• Identifying the clinical and operational reason for the transfer.
• Determining whether earlier recognition or intervention could have changed the outcome.
• Identifying gaps in assessment, communication, orders, staffing, supplies, or follow-up.
• Developing corrective actions with the interdisciplinary team.
• Tracking hospital transfers and readmissions by resident, diagnosis, shift, unit, and contributing factors.
• Reporting trends to the DON, Administrator, Medical Director, and QAPI committee.
• Monitoring outcomes and recommending process improvements.

Qualifications

• Current Florida LPN/RN license.
• Associate degree in nursing required; BSN preferred, but not required.
• Current BLS certification.
• Previous nursing-home, long-term-care, acute-care, emergency, rehabilitation, or geriatric nursing experience preferred.
• Strong clinical assessment and critical-thinking skills.
• Excellent communication and documentation skills.
• Ability to recognize clinical deterioration and appropriately escalate care.
• Knowledge of nursing-home regulations, resident rights, and standards of nursing practice.
• Experience with electronic medical records preferred.

Preferred Experience

• Hospital readmission or hospital-transfer reduction programs
• QAPI
• Clinical risk management
• Care transitions
• Geriatric nursing
• Infection prevention
• Wound care
• CHF/COPD management
• Staff education
• SBAR and standardized change-in-condition tools

Key Performance Indicators

Success in this position may be measured through:

• Reduction in avoidable hospital transfers
• Reduction in hospital readmissions
• Percentage of changes in condition successfully managed in the facility when clinically appropriate
• Timeliness of provider notification
• Timeliness of post-hospital follow-up
• Completion of medication reconciliation
• Reduction in repeat transfers for the same clinical issue
• Completion of transfer root-cause reviews
• Staff compliance with change-in-condition protocols
• Resident outcomes and satisfaction

Important: Hospital-transfer reduction is a quality-improvement objective, not a requirement to avoid hospitalization. The nurse must use independent clinical judgment and promptly arrange emergency evaluation or transfer whenever the resident's condition warrants a higher level of care