Primary Care Healthcare Home Nurse Care M

The Heart Failure (HF) Program Care Navigation Liaison improves outcomes by reducing all cause readmissions and coordinating episodes of care among patients in a defined population or disease process. The primary focus is on the coordination and delivery of efficient, effective, compassionate, patient centered care and safe transitions across the care continuum. The HF Program Care Navigation Liaison monitors the patient care process and physiological needs; educates, documents, communicates, and collects data to evaluate and assure patient/family readiness for discharge. The HF Program Care Navigation Liaison facilitates the lateral integration of the care team, collaborating with physicians, nurses and other staff across the continuum to provide comprehensive disease management, assessment, treatment, education, and follow‑up evaluation for patients; and to communicate the plan of care in coordination with post‑acute care settings. The HF Program Care Navigation Liaison ensures a fluid integration of all willing patients discharging with a primary diagnosis of HF and are followed for Care Navigation services in the ambulatory space and serves as a liaison with post‑acute partners including, but not limited to, CVS, Wellsky, and others as determined by the HF Leadership team.

Liaison / Care Coordination (50% of time)

Serves as a liaison to ensure enrollment of appropriate HF patients with post‑acute partner organizations

Communicates with post‑acute partners on HF patient care plans as needed

Coordinates the evaluation process of the HF patient population, may complete and document portions of the evaluation process, collaborating with other team members to ensure completion of all required information

Is a liaison between the medical team, staff nurses, consult teams, ancillary staff, Ambulatory Care Navigation services, PCP, and patients; coordinates ancillary consults and suggests possible patient needs including PT, OT, cardiac rehab, palliative care, and social services

Reviews medical team documentation and consults as a basis for intervention

Develops and manages processes related to pre‑admission and post‑discharge care transitions

Establishes relationships/clinical pathways with providers/agencies to optimize care for the defined patient population

If the patient is identified in an acute care setting as high risk, may perform or consult for face‑to‑face assessment of the patient; if a readmission, RN collaborates with IP Case Manager and conducts a patient interview to review possible causes

May participate in attending rounds to fully understand the plan of care, provide decision support and focus the team on the expected course of disease management

Develops and proactively consults for or modifies a care plan with the medical team for each patient by assessing educational needs in conjunction with caregivers; Interacts with consulting physicians, HF Program Lead APP, and other health care providers internally and externally to assure the progression of the plan of care and externally to facilitate follow‑up care

Consults for and acts as liaison with multidisciplinary care conferences including ethics discussions, develops concise patient care plans for use by the team, and documents recommendations made utilizing standardized care protocols in accordance with nationally recognized care guidelines; Collaborates with and assists case managers in discharge planning, identifying outpatient needs and follow‑up care, and arranging for discharge prescriptions

For patients requiring additional Care Navigation services beyond the first 30 days post‑discharge, contacts patients within an established timeframe and at designated intervals to assess patient status, answer questions, provide education, and facilitate communication with physicians as indicated

Serves as a clinical point person for outpatient phone calls regarding symptom management, post‑acute care, and follow‑up; Using established criteria, may make home visits to patients or post‑acute facilities to determine adherence to discharge instructions including medication management and keeping appointments; assesses the appropriateness of the post‑acute setting, adherence to the care plan, transportation and support system needs and responds accordingly

Communicates, verbally and in written form, with referring physicians, primary care physicians, home care agencies, ambulatory care navigation teams, and post‑acute facilities when applicable

Displays thorough and accurate documentation of all communications throughout the episode of care

Works in conjunction with the HF Program Lead APP to ensure all HF patients are provided an opportunity to enter the HF Care Program

Brainstorms and develops efficiency opportunities for the team and patients regarding education, process improvement, and quality improvement

Introduces and engages patients in post‑acute services provided by the HF Care Team and re‑enforces education provided by bedside nursing regarding HF care when possible

standardizes content and delivery

Responsible for outreach efforts with home care agencies, skilled nursing facilities, LTACHs, and other community agencies to provide disease‑specific education

Quality Improvement (25% of time)

Participates in administrative meetings, task forces, committees, and projects with disease process focus

Maintains patient tracking tool and discharge database for all patient encounters

assists with disease‑specific program improvement projects

Participates in readmission and other related projects as indicated

Maintains an awareness of Medicare Conditions of Participation related to discharge planning

For Hire - Registered Nurse and BSN required; Case management and post‑acute care experience (home care, SNF, LTACH) desirable.

The university is an equal opportunity employer, including veterans and disability.

#J-18808-Ljbffr The Ohio State University Wexner Medical Center