Description
**Discover Vanderbilt University Medical Center:** Located in Nashville, Tennessee, and operating at a global crossroads of teaching, discovery, and patient care, VUMC is a community of diverse individuals who come to work each day with the simple aim of changing the world. It is a place where your expertise will be valued, your knowledge expanded, and your abilities challenged. Vanderbilt Health recognizes that diversity is essential for excellence and innovation. We are committed to an inclusive environment where everyone has the chance to thrive and where your diversity of culture, thinking, learning, and leading is sought and celebrated. It is a place where employees know they are part of something that is bigger than themselves, take exceptional pride in their work and never settle for what was good enough yesterday. Vanderbilt's mission is to advance health and wellness through preeminent programs in patient care, education, and research.
**Organization:**
Hematology/Oncology
**Job Summary:**
Assists in developing and meeting key Pillar outcomes and system improvement goals including financial, satisfaction, and clinical as the nursing component of the care coordination model. This position Improves outcomes by reducing all cause hospital readmissions and coordinating episodes of care among patients in a defined population or disease process. Participates in identification of appropriate VAMP patients; facilitates referrals to other VAMP subspecialty providers; encourages VAMP patient and family engagement in self-care management; promotes warm handovers to the next level of care by providing timely, pertinent information in a standardized way; conducts VAMP patient and family education on key elements of the patients' personal care plan by using the "teach-back" methodology and follow up phone calls; assists the patient in navigating the VAMP healthcare system. Position additionally assumes responsibility of attending all VAMP multidisciplinary meetings and recording of predetermined relevant clinical information on all VAMP patients under VAMP care at the VUMC.
Basic and Preferred Qualifications:
Bachelor's Degree (or equivalent experience) Bachelor's in Nursing (Required)
5 years relevant experience (Required)
Registered Nurse (Required)
Bachelor's in Nursing or Healthcare related field (Required)
Bachelor's of Science in Nursing (Preferred)
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KEY RESPONSIBILITIES
- Coordinates the evaluation process of the defined VAMP patient population. May complete and document portions of the evaluation process, collaborating with other team members to ensure completion of all required information.
- Supports VAMP patient access by serving as a liaison between the referring provider's office and Vanderbilt VAMP provider.
- Interacts routinely and effectively with the VAMP clinical team to develop a collaborative plan for the coordination of patient care from the anchor hospitalization through the defined care episode.
- Develops and manages the processes related to pre-admission and post-discharge care transitions; establishes relationships/clinical pathways with providers/agencies to optimize care for defined VAMP patient population.
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- Assists in the development and dissemination of VAMP patient education materials/information to include creation of customized medication grids with input from the pharmacist/team as needed.
- Assists with discharge/transition planning in collaboration with the VAMP multi-disciplinary team, actively engaging outpatient care providers by sharing hospital course, concerns, pending test results, learning needs, partnership opportunities etc.
- Coordinates handovers including outpatient care coordinators (disease management teams), home health care nurses, cardiac rehab, skilled nursing facilities, etc.
- Demonstrates reflective practice by constantly evaluating care coordination and supports the development of VAMP protocols for practice based on evidence
- Attends all VAMP multidisciplinary q2 weekly meetings and records predetermined relevant clinical decisions on all VAMP patients
- Keeps record of all VAMP treated patients together with predetermined variables in preselected VAMP data base
- The responsibilities listed are a general overview of the position and additional duties may be assigned.
TECHNICAL CAPABILITIES
RN ACCESS PATIENT EDUCATION (ADVANCED):
- Demonstrates uppermost levels of patient education in practical applications of a complex nature. Possesses mastery of knowledge, training, and expertise to be capable of successfully delivering treatment planning services across the care continuum. Takes a lead role in complex situations when there is a need to achieve results. Actively participates in outside professional organizations and forums.
NURSING PATIENT ASSESSMENT & EVALUATION (ADVANCED):
- Demonstrates the uppermost levels of expertise in patient assessment and evaluations in challenging and complex situations. Conducts primary care patient interviews and physical examination. Often takes a lead role in complex patient care situations. Possesses expert knowledge, training and experience to mentor less experienced peers.
EVIDENCE-BASED PRACTICE (ADVANCED):
- Recognizes, Implements, and evaluates practice changes based on published research. Demonstrates expertise in applying evidence-based practices to challenging and complex situations.
TREND ANALYSIS (INTERMEDIATE):
- Demonstrates mastery of trend analyses. Can recognize the impact and take into consideration the effect of seasonality and randomness. Has analyzed trends in detecting patterns that could lead to future problems and in forecasting future demand periods. Has worked in several areas that might include sales, marketing, quality, finance and manufacturing.
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CORE ACCOUNTABILITIES
- Organizational Impact: Delivers projects/assignments that have a direct impact on goals/objectives of the unit/department that the job is in.
- Problem Solving/ Complexity of work: Conducts extensive analysis of situations or data to resolve numerous, complex issues; may involve the input/work of others.
- Breadth of Knowledge: Has in-depth level of knowledge within a professional area and working knowledge of other areas.
- Team Interaction: May lead mid-sized projects; coaches and guides team members.
CORE CAPABILITIES
SUPPORTING COLLEAGUES (P4):
- Develops Self and Others: Invests time, energy and enthusiasm in developing self/others to help improve performance and gain knowledge in new areas.
- Builds and Maintains Relationships: Maintains regular contact with key colleagues and stakeholders using formal and informal opportunities to expand and strengthen relationships.
- C
Compensation Information:
$0.0 / - $0.0 /
Starting At: 0.0
Up To: 0.0
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