Supervisor RN Transitional Care - Care Continuum Community Health Job Listing at Health First Medical Group in Rockledge, FL (Job ID 3987500-2024-07-23)

Description

Description

POSITION SUMMARY:

To be fully engaged in providing Quality/No Harm, Customer Service and Stewardship by performing care management within the scope of licensure for patients with complex and chronic care needs by assessing, developing, implementing, coordinating, monitoring, and evaluating care plans and disease specific education designed to optimize patient health care across the care continuum. Transitional Care Navigators work within a defined patient population to promote the achievement of optimal clinical and resource outcomes. Transitional Care Navigators utilize independent clinical judgment and works collaboratively with the interdisciplinary team to promote quality of care through collaboration with all team members, patients, families and significant support personnel. Transitional Care Navigator serves as an educational resource for patients, care givers and staff members. This includes meeting with patients, bedside, at the patient's home and/or telephonically. The will assist patients set realistic health goals and provide support in reaching those goals through education, care coordination, and support. Transitional Care Navigator performs overall coordination of care for identified patients via telephonically or on?site such as at hospitals, in?home, or various placements after discharge. This position has direct supervisory responsibilities for all the RN Transitional Care Navigators within the department (IDN wide, 4 hospitals)

PRIMARY ACCOUNTABILITIES:

Quality/No Harm:

• Completion of all Mid?year and annual evaluations of all RN Transitional Care Navigators within the department (IDN wide, includes all 4 hospitals).
• Scheduling of all RN Transitional care Navigators to ensure 7 days a week coverage across the IDN.
• Schedules and facilitates individual and team meetings with all RN Transitional Care Navigators within the IDN (frequency based on needs of team and individuals,) minimum on a monthly basis.
• Timekeeping and Kronos scheduling/approval for direct reports.
• The Transitional Care Navigator plans effectively to meet patient needs during their hospital stay regarding processing them through the system and managing the length of stay, promoting efficient utilization of resources, and plans for a safe discharge continually evaluating and updating patient status. Specific functions within this role include:
  
  • Facilitation of patient's transitional plan in collaboration with the physician, nursing and interdisciplinary team.
  • Facilitation of the collaborative management of patient care across the continuum, intervening as necessary to remove and escalate barriers to timely and efficient care delivery.
  • Application of process improvement methodologies in evaluating outcomes of care.
  • Identifies at?risk populations using approved screening tool and follows established referral processes for patients.
  • Promotes professional practice through collegial support and interactions.
  • Practices autonomously, consistent with evidence?based standards.
  • Using identified reports, works collaboratively with Care Transitions team to identify high risk patients and assure safe transition to the next level of care to prevent readmissions.
  • Utilize motivational interviewing and engagement strategies to support overall health, wellness of patients and self?management which includes employing behavior change/motivational interviewing skills to assess readiness, health goal setting short and/or long term needs, engage patient's plans for change following standard policy and procedures, clinical guidelines and national evidenced?based criteria.
  • Document interactions and interventions as directed with health technology, risk stratification and patient engagement tools.

Stewardship:

• Provides health coaching activities across the continuum of care in order to facilitate and promote high quality, cost?effective outcomes, focused on the whole patient orientation and self? management decision support and aims to minimize any fragmentation of health care delivery.
• Supports system?wide efforts pertaining to alternative payment models and reductions in Medicare Spending (MSPB).
• Identify cost savings options for patients.
• Addresses/resolves system problems impeding diagnostic or treatment progress.
• Proactively identifies resolves or escalates delays and obstacles.
• Demonstrates understanding of level of care criteria and reimbursement factors for home care, rehabilitation, outpatient treatment, residential treatment and long term care in development of discharge plans. Seeks alternatives to discharge planning, and creates relationships with all supportive organization to help in the discharge process.

Customer Experience:

• Demonstrates positive customer relations in all settings and circumstances.
• Demonstrates strong I?CARE values.
• Possess strong empathy skills and able to develop strong rapport with patients.
• Demonstrates effective communication with other members of the healthcare team and promotes effective team functioning.
• Provides patient, family, and/or caregiver education as directed by the plan of care.
• Provides service to patients and families with sensitivity and respect for their needs, expectations, age, cultural, and individual differences.
• Works with the physician advisor, physicians, nursing, ambulatory programs, outpatient programs, interdisciplinary team and health plan for defined patient populations to develop clinical appropriate transitional pathways, continuum care management for patient care and patient satisfaction.
• Coordinates/facilitates patient care progression. Review discharge needs at time of admission, and assists with the transition of care through hospital say and discharge.
• Works collaboratively and maintains active communication with physicians, nursing, physician advisor, and other members of the interdisciplinary care team to effect timely, appropriate patient resource management, and patient transition.
• Seeks consultation from appropriate disciplines/ancillary departments as required to expedite care and facilitate patient transition.
• Demonstrates positive customer relations in all settings and circumstances.
• Promotes patient's independence by establishing patient care goals; teaching and counseling patient, friends, and family and r...