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Job Overview
This position, in conjunction with Case Management, coordinates the transition of care from one health care setting to another which includes : inpatient, Home Health Care, Skilled Nursing Facility, Rehab facilities. Educates the patient and/or family regarding the patient's clinical condition, treatment, postoperative course, and the patient's role in recovery. Collaborates and communicates with a wide range of multidisciplinary providers with the goal of achieving an exceptional patient experience and the best possible patient outcomes .
Job Description
Duties and Responsibilities : The duties and responsibilities listed below are intended to describe the general nature of work and are not intended to be an all-inclusive list . Other duties and responsibilities may be assigned.
Inpatient Care
- Identifies eligible inpatients using established program criteria
- Delivers education to the patient and caregivers, including teach back interventions
- Performs risk assessment using standardized tool
- Supports non-cardiology primary providers with HF guideline directed medical therapies plan, including liaising with pharmacy
Transitions of Care
- Collaborates with other members of inpatient care team to develop discharge care plan
- Coordinates post-discharge care to ensure seamless transition
- Collaborates with pharmacist on medication reconciliation
- Schedules post-discharge clinic appointments
- Communicates with patient's PCP and post-acute care providers regarding post-discharge care expectations
- Develops a plan for scheduled check-ins with patients and caregivers
Post-Discharge Care
- Calls patient by phone at pre-determined intervals
- Ensure patient adherence with care plan (eg, medications, self-monitoring)
- Communicates closely with the patient and their family during the first 30 days post-discharge to ensure they are fully informed and supported during the transition period
- Reminds patients of upcoming appointments
- Helps resolve obstacles to adherence and wellbeing
Data Collection
- Collects and documents key data points into appropriate systems (eg, risk assessment score)
- Helps provide QA of appropriate systems to ensure data integrity
- Performs interval reviews of readmission cases to identify opportunities for improvement
Program Development
- Recommends improvements or development of standards of practice for inpatient, post-acute, home and ambulatory care of patients
- Participates in the development and evaluation of program tools and interventions, such as patient education materials, risk assessment tools, and databases
- Provides educational in- and outreach to providers in the network
- Works in collaboration with heart failure disease management NP and RN
Qualifications
- Bachelor of Science degree in Nursing
- Registered nurse with current unrestricted Massachusetts state license
- Heart failure nurse certification highly desirable
- Minimum of 5 years of clinical nursing experience working with heart failure cardiology patient population
Tufts Medicine is a leading integrated health system bringing together the best of academic and community healthcare to deliver exceptional, connected and accessible care experiences to consumers across Massachusetts. Comprised of Tufts Medical Center, Lowell General Hospital, MelroseWakefield Hospital, Lawrence Memorial Hospital of Medford, Care at Home - an expansive home care network, and large integrated physician network. We are an equal opportunity employer and value diversity and inclusion at Tufts Medicine. Tufts Medicine does not discriminate on the basis of race, color, religion, sex, sexual orientation, age, disability, genetic information, veteran status, national origin, gender identity and/or expression, marital status or any other characteristic protected by federal, state or local law. We will ensure that individuals with disabilities are provided reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. Please contact us to request accommodation by emailing us at (see below) .