RN Transitional Care Nurse â€"IN Integrated Market
Location: Indianapolis Indiana
Description: Kindred Healthcare is presently looking of RN Transitional Care Nurse â€"IN Integrated Market right now, this vacancy will be placed in Indiana. Further informations about this vacancy opportunity please read the description below. (
Job Number:
136342
)
Description
Summary:
The
Transitional Care Nu! rse will coordinate patient care across the continuum of healthcare delivery systems.
The healthcare delivery systems include the acute care setting (hospital); Transitional Care Hospitals; Transitional Care Centers; Home Health; Palliative Care; and, as appropriate, Hospice.
The TCN will incorporate the skills of an advanced nurse practitioner, care manager, educator, advocate, and interdisciplinary team member to provide evidence-based coordination and plan of individualized, realistic care that will promote positive outcomes.
Emphasis will be placed on active patient/family participation and collaboration with healthcare members and providers to improve care, decrease complications and exacerbations, and to prevent and/or decrease hospitalizations.
Essential Functions:
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Assume the primary role in managing patients and coordinating transitions of care.
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Implement the Nursing Process to create in! dividualized care plans that focus on the patient's condition(! s) and attain positive outcomes.
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Evaluate progress towards goals/outcomes and, as necessary, change the plan of care accordingly.
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Manage the development and analysis of statistical data and specifications to determine benchmark standards for outcomes related to disease conditions, hospitalizations, Emergency Department visits, and exacerbations.
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Interpret/translate patient care information to ensure that patient/family is able to understand and follow the plan of care.
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Perform medication reconciliation and instruct patient/family on all aspects of medication management/administration.
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Teach patient/family the knowledge and skills necessary to decrease or eliminate exacerbations, complications, and/or hospitalizations, and assess their ability to do so.
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Utilize patient education to encourage patients/family to make prevention and wellness priorities. !
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Implements a comprehensive discharge planning and home follow up protocol.
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Foster collaboration of patient/family with physicians, nurses, social services, dieticians, therapy, discharge planners, pharmacists, case managers, and other healthcare members to ensure a multidisciplinary approach to care.
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On admission, conduct a comprehensive assessment of the patient's health status and utilize this information to coordinate an individualized plan of care and appropriate services.
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Following admission, meet directly with the patient to explain role and how Kindred intends to improve the patient’s transition to the next level of care.
The TCN conducts an ‘at the bedside’ meeting with the patient and caregiver to identify and discuss the patient’s reason(s) for admission, care plan, expected length of stay, goals and anticipated post-discharge care needs.
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Atten! ds weekly Interdisciplinary Team Meetings (IDT), reviews the patient’! s medical record, and gathers clinical information from the current care delivery team and the patient in order to assess progress toward discharge and anticipated length of stay.
Also coordinates discharge goals of patient/family.
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Provides information - including Kindred collaterals - to patients and their caregivers about Kindred's post acute discharge options and collaborates with Sales and Marketing as needed.
Adheres to Kindred’s Patient Choice Policy and Procedure at all times.
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Collaborates with members of the interdisciplinary team by gathering information required to develop a safe and effective transitional plan to the next level of care.
Ensures clinical and personal transitional goals are met throughout each level of care to promote optimal recovery.
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Advocates on behalf of the patient and the healthcare provider for needed patient resources and services.
·
and
in writing to the receiving provider as the patient transitions from one level of care to the next (includes bidirectional admissions or discharges).
Responsible for the management and accurate completion of appropriate service line-specific discharge documentation and presence of physician’s dictated discharge summary as well as verification that proper discharge education, disease management, medication review, equipment and supply needs, restrictions, patient-stated goals and contact information for the next level of care have been reviewed with, and understood by, the patient, their caregiver and the receiving provider.
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Provides telephonic and/or onsite support to all patients who are transitioned to the next level of care and conducts patient survey within 72 hours post transition.
All pertinent information collected will be reviewed and assessed with appropriate healt! hcare team providers and the patient’s PCP.
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Cont! acts the patient’s PCP with each transition of care, providing a summary of the patient's clinical status with an emphasis on increasing the patient's and caregivers’ ability to manage their care once discharged back to the community.
Collaborates with the PCP to provide direction to enhance the effectiveness of the healthcare delivery team, including transitions across the continuum of care.
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Monitor and manage changes in health status to improve patient care and outcomes.
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Maintains documentation of each patient encounter, including teaching and discharge instructions.
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Assists SDCM and works with IS and other departments to develop clinical information systems for evidence-based assessment tools, intervention protocols and documentation, tracking patient visits, and data collection and reporting.
Monitors and collects data to evaluate the effectiveness and the quality of patient care in the! post-acute care continuum.
Qualifications
Qualifications:
Education:
·
BSN and MSN from an accredited School of Nursing.
Licenses/Certifications:
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Valid RN and NP license in the State of Indiana
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Case Management certification from an accredited organization strongly preferred
Experience:
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Five years of experience in a transitional care environment.
Working directly with Medicare and Managed Care services preferred.
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Five years of experience as a Case Manager with strong skills and knowledge of discharge planning, community resources and medical management preferred.
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Excellent managerial references are required.
Knowledge/Skills/Abilities:
Ability to work independently and collaboratively with other healthcare team members
Ability and willingness to self-motivate, pr! ioritize, and implement change in order to improve effectiveness and ef! ficiency; ability to adapt to changing patient or organizational priorities
Ability to manage conflict, stress, and multiple simultaneous work demands in an effective and professional manner
Ability to make independent decisions in accordance with established policies and procedures; decision making and problem solving will require a combination of analysis, evaluation, and interpretive thinking
Knowledge and appreciation of cultural diversity in the provision of care
Demonstrates advanced clinical assessment skills
Superior interpersonal, verbal and written communication skills and ability to communicate effectively with patients and their family members as well as physicians and colleagues at all levels of the organization
Knowledge of reimbursement methods and regulations (Managed Care, Medicare & Medicaid) that promotes the provision of cost effective healthcare and the preservation of patient’s benefits while obta! ining optimal recovery and managing a clinically appropriate length of stay
Computer literacy, including proficiency in MS applications but not limited to data entry and/or report generation
Detail oriented with a focus on accuracy while effectively managing multi-site duties
Ability to work in a start-up environment which will require innovation, flexibility, critical thinking and ability to adapt to and recommend change
Able to maintain patient confidentiality at all times and to ensure patient rights are protected
Highly organized and capable of self scheduling to ensure all patient encounters are completed on time
Ability to travel to and from a variety of care settings in varying weather conditions
Service Excellence Elements:
Pride
â€" (Owning and feeling proud of work quality and our mission.)
Performs work that reflects ownership and is a credit to self and positively represe! nts Kindred.
Teamwork
â€" (Achieving greater results ! through cooperation and recognizing contributions.)
Cooperates with co-workers while performing duties leading to everyone being able to achieve success and giving recognition where it is due.
Compassion
â€" (Listening and focusing on the patient/resident; taking sincere, appropriate actions.)
Meets the patients’ needs and concerns by consistently acting in a patient-focused manner.
Integrity
â€" (Doing the right thing.)
Demonstrates adherence to a strict moral or ethical code in performance of duties by always seeking to do the right thing.
Respect
â€" (Treating others as they would like to be treated; valuing others.)
Acknowledges the worth of others through professional greetings, proper telephone etiquette, patience, and common courtesy.
Fun
â€" (Enjoying work and being an enthusiastic participant.)
Demonstrates a positive attitude toward work and devot! ion to the task at hand.
Professionalism
â€" (Assuring skills (licensures) are current; looking and acting the part while performing at the highest level.)
Keeps skills, competencies and required licensures/certifications current; displays mastery over attitude and behavior and pride in appearance. Consistently performs duties to the best of abilities.
Responsibility
â€" (Being accountable, doing what is expected or beyond; assuring what needs to get done, gets done.)
Takes ownership of all aspects of duties shown through reliable, timely performance and accountability.
Company Specific:
·
Adheres to dress code, appearance is neat and clean and wears appropriate identification while on duty.
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Completes annual health, safety, and education requirements.
Maintains professional growth and development.
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Maintains confidentiality of all patient and! /or employee information to assure patient and/or employee rights are p! rotected.
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Demonstrates knowledge of the principles of growth and development over the life span and the skills necessary to provide age appropriate care to the patient population served.
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Reports to work on time as scheduled; adheres to policies regarding notification of absence.
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Attends all mandatory in-services and staff meetings.
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Represents the organization in a positive and professional manner.
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Complies with all organizational policies regarding ethical business practices.
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Communicates the mission, ethics, and goals of the hospital, as well as the focus statement of the department.
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Maintains current licensure/certification for position, if applicable.
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Consistently demonstrates Guest Relation’s skills to patients, physicians, visitors, employees, and any other individuals with whom they may come in contac! t.
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Consistently follows departmental and hospital Health, Safety, Security, Hazardous Materials policies and procedures. HIPAA: Conduct job responsibilities in accordance with HIPAA privacy laws, follow hospital policy in provision of patient confidentiality. Able to identify patient confidentiality issues and reports to proper hospital personnel immediately.
·
Compliance: Conducts job responsibilities in accordance with standards set forth in Kindred’s Code of Conduct, Kindred policy and procedures, applicable federal and state laws, and applicable standards.
If you are a current
Kindred/RehabCare employee
Click Here
.
Job
:
RN
Primary Location
:
IN-Indianapolis-Central Indiana District
- .
If you were eligible to this vacancy, please email us your resume, with salary requirements and a resume to Kindred Healthcare.
If you interested on this vacancy just click on the Apply button, you will be redirected to the official website
This vacancy starts available on: Fri, 15 Mar 2013 18:04:35 GMT
Apply RN Transitional Care Nurse â€"IN Integrated Market Here
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