RN Transitional Care
Olney, MD 
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Posted 4 months ago
Position No Longer Available
Position No Longer Available
Job Description
Job Summary This position has primary responsibility for the independent assessment, planning and evaluation of nursing care for patients in the target diagnosis groups at high risk for readmission, from admission through discharge. In collaboration with the patient and family, coordinates evidence-based professional nursing care and coordinates care delivery with the physician and other members of the health care team to ensure appropriate interventions are implemented to ensure a safe discharge and reduce the patient risk of readmission. These interventions include, but are not limited to: use of clinical pathways, patient education, and coordination of post-discharge medical appointments, medications, and equipment. Minimum Qualifications Education/Training Associates degree/Diploma in Nursing, Bachelor#s degree preferred # Experience Minimum 5 years experience in nursing, preferably with experience in discharge planning, case management or home health care. # License/Certification/Registration Maryland Nursing License # Knowledge, Skills # Abilities Ability to read, write, speak, and comprehend English. Strong organizational skills. Basic Computer skills to perform Data entry utilizing the following software: Microsoft Office, Clinician View # Chart View. HIPAA policies on Confidentiality Primary Duties and Responsibilities Patient Transition Coordination: Facilitates patient care by ensuring that proper interventions are implemented to ensure a safe discharge and reduce the risk of patient readmission. Facilitates safe and effective transition for the patient and their family. Coordinates transition for patients in target diagnosis groups from admission through discharge to ensure that appropriate interventions are implemented to ensure a safe discharge and reduce patient risk of readmission. Collaborates with physicians, nurses, social workers, pharmacists and other members of the health care team with a focus on increasing the patient and caregiver#s ability to manage their care. Communicates patient clinical information clearly and accurately in verbal and written format to primary care physician, patient and family. Clearly and accurately documents pertinent information in patient medical record. Consistently demonstrates effective documentation practices. Completes timely initial and ongoing patient assessments, considering all aspects of the patient#s clinical and social needs. Evaluates patient response to treatment and progress toward identified goals and revises plan as appropriate using critical thinking. Reports patient changes to appropriate team members. Identifies health teaching needs of patient and family. Works with other members of health care team to develop, implement, and evaluate health teaching program to meet identified needs. Effectively uses and adapts a variety of teaching resources in meeting the learning needs of patient/family. Promotes patient and family self-management of their disease. Coordinates discharge planning activities in collaboration with other members of the healthcare team. Implements a comprehensive discharge plan that includes: follow-up phone calls, medication and symptom management, post-discharge medical appointments and other activities necessary to prevent frequent hospital and emergency department use Contributes to the achievement of established departmental goals and objectives and adheres to departmental policies, procedures, quality standards and safety standards. Complies with governmental and accreditation regulations. Seeks opportunities to participate in developing/revising standards of practice to meet change patient population requirements. Maintains databases on care transition population. Maintains accurate and timely documentation. Collects and analyzes data on clinical indicators to identify opportunities for improvement. Develops, prepares and presents related records and reports. Participates in measuring clinical outcomes, data procurement and analysis activities. Performs other duties as necessary to promote the safe discharge of patients and prevention of re-admissions. Development: Maintains current knowledge, certification, and licensure. Identifies learning needs in self and initiates actions to address these education needs. Attends continuing education programs in order to maintain certification. Attends hospital sponsored training programs as required by the department. Assists in the development of new programs to improve quality of care and/or reduce unnecessary expenses. Completes all mandatory requirements, certifications, and licensure within allotted timeframe for completion (License, PPD, Competencies, Age Specifics, etc.) Organizational knowledge: Works effectively within and between departments. Participates on inter-departmental teams and committees, communicating unit knowledge as appropriate Provides department/unit with information and knowledge acquired during participation with interdepartmental teams and committees. Demonstrates a constructive approach during all interactions with staff, supervisors, and managers both inside and outside the unit.# * Job Summary * This position has primary responsibility for the independent assessment, planning and evaluation of nursing care for patients in the target diagnosis groups at high risk for readmission, from admission through discharge. In collaboration with the patient and family, coordinates evidence-based professional nursing care and coordinates care delivery with the physician and other members of the health care team to ensure appropriate interventions are implemented to ensure a safe discharge and reduce the patient risk of readmission. These interventions include, but are not limited to: use of clinical pathways, patient education, and coordination of post-discharge medical appointments, medications, and equipment. * Minimum Qualifications * Education/Training * Associates degree/Diploma in Nursing, Bachelors degree preferred * * Experience * Minimum 5 years experience in nursing, preferably with experience in discharge planning, case management or home health care. * * License/Certification/Registration * Maryland Nursing License * * Knowledge, Skills & Abilities * Ability to read, write, speak, and comprehend English. * Strong organizational skills. * Basic Computer skills to perform Data entry utilizing the following software: Microsoft Office, Clinician View & Chart View. * HIPAA policies on Confidentiality * Primary Duties and Responsibilities * Patient Transition Coordination: Facilitates patient care by ensuring that proper interventions are implemented to ensure a safe discharge and reduce the risk of patient readmission. * Facilitates safe and effective transition for the patient and their family. Coordinates transition for patients in target diagnosis groups from admission through discharge to ensure that appropriate interventions are implemented to ensure a safe discharge and reduce patient risk of readmission. * Collaborates with physicians, nurses, social workers, pharmacists and other members of the health care team with a focus on increasing the patient and caregivers ability to manage their care. * Communicates patient clinical information clearly and accurately in verbal and written format to primary care physician, patient and family. Clearly and accurately documents pertinent information in patient medical record. Consistently demonstrates effective documentation practices. Completes timely initial and ongoing patient assessments, considering all aspects of the patients clinical and social needs. Evaluates patient response to treatment and progress toward identified goals and revises plan as appropriate using critical thinking. Reports patient changes to appropriate team members. * Identifies health teaching needs of patient and family. Works with other members of health care team to develop, implement, and evaluate health teaching program to meet identified needs. Effectively uses and adapts a variety of teaching resources in meeting the learning needs of patient/family. Promotes patient and family self-management of their disease. * Coordinates discharge planning activities in collaboration with other members of the healthcare team. Implements a comprehensive discharge plan that includes: follow-up phone calls, medication and symptom management, post-discharge medical appointments and other activities necessary to prevent frequent hospital and emergency department use * Contributes to the achievement of established departmental goals and objectives and adheres to departmental policies, procedures, quality standards and safety standards. Complies with governmental and accreditation regulations. Seeks opportunities to participate in developing/revising standards of practice to meet change patient population requirements. * Maintains databases on care transition population. Maintains accurate and timely documentation. * Collects and analyzes data on clinical indicators to identify opportunities for improvement. Develops, prepares and presents related records and reports. Participates in measuring clinical outcomes, data procurement and analysis activities. * Performs other duties as necessary to promote the safe discharge of patients and prevention of re-admissions. * Development: Maintains current knowledge, certification, and licensure. * Identifies learning needs in self and initiates actions to address these education needs. * Attends continuing education programs in order to maintain certification. * Attends hospital sponsored training programs as required by the department. * Assists in the development of new programs to improve quality of care and/or reduce unnecessary expenses. * Completes all mandatory requirements, certifications, and licensure within allotted timeframe for completion (License, PPD, Competencies, Age Specifics, etc.) * Organizational knowledge: Works effectively within and between departments. * Participates on inter-departmental teams and committees, communicating unit knowledge as appropriate * Provides department/unit with information and knowledge acquired during participation with interdepartmental teams and committees. * Demonstrates a constructive approach during all interactions with staff, supervisors, and managers both inside and outside the unit.

 

Position No Longer Available
Job Summary
Company
Medstar Research Institute
Start Date
As soon as possible
Employment Term and Type
Regular, Full Time
Required Education
Associate Degree
Required Experience
5+ years
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