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RN-Telephone Transition Support - Full-time / Part-time
•30 days ago
| Hours | Full-time, Part-time |
|---|---|
| Location | Ann Arbor, MI Ann Arbor, Michigan |
About this job
Bachelor's Degree
1 - 3 years of experience required
POSITION PURPOSE The Transition Support Call RN specializes in providing information and post-discharge support for the patient in identifying concerns and problems and building relationships. In this role, the Transition Support Call RN provides information and guidance to the patient/caregiver for effective care transitions, improved self-management skills and enhanced patient-practitioner communications. Call-back intervention service is based on SJMH Care Transition Program's methodology that encourages the patient to assume a more active role in their care and facilitate new behaviors and communication skills for patients to feel confident in their ability to respond successfully to common problems that arise during care transitions. This is achieved by coordinating care and service for defined patient populations during post discharge phone contact within the first post discharge week. The Transition Support Call RN works collaboratively with an interdisciplinary team to improve patient care through the effective utilization of the Health System's resources.
The Transition Support Call RN is an essential part of SJMHS Care Transitions Program. Evidence-based research supports significant benefit toward reducing System lost-revenue generated by avoidable 30-day readmissions, and significant improvement in patient satisfaction for the entire hospital episode through Transition Support Call-Back Services. The Transition Support Call RN demonstrates effective Relationship Centered service and Outcomes Based communication skills.
ESSENTIAL FUNCTIONS AND RESPONSIBILITIES
1. Assessment:
* Conducts a focused assessment as it relates to a patient's needs for transition of skill preparation.
2. Utilization Management:
* Performs assessment of intensity of service criteria for defined patient population.
3. Planning:
* Contributes to the development of age appropriate transitional plan of care through a team process that is prioritized based on medical diagnosis, patient needs, expected patient outcomes, and patient phone interaction capability.
* Ensures that all activities to facilitate and coordinate the transition plan are being implemented and that the plan is modified as needed based on patients' needs.
4. Communicates as appropriate, effectively, to:
* Guide patient towards patient's identification of needs to appropriate professionals and follows up (PCP, Specialists, Pharmacist, Therapist, Home Care staff, dietician, etc.)
* Guide patient toward maintenance of contact on a regular basis to interdisciplinary care team members: to empower patient capability of coordination of clinical activities and to enhance the effect of a seamless transition from one level of care to another across the continuum.
5. Implementation:
* Guide patients toward skill transfer of self-management to procure health system and community services and resources needed by patients and families in order to reach stated personal and health goals.
6. Collaboration:
* Serves as a resource and provides direction to patients.
* Fosters positive internal and external relationships with colleagues and associates
7. Outcomes:
* Continually evaluates Transition Support Call services and client outcomes.
8. Critical Thinking:
* Is knowledgeable about and acts in accordance with laws and procedures regarding patient confidentiality and release of information, Americans With Disabilities Act, other laws protecting rights, and workers' compensation laws when applicable to the Transition Support Call RN's practice.
9. Quality Performance/Improvement:
* Participates in the development, implementation, evaluation and ongoing revision of initiatives to improve quality, continuity and cost effectiveness of care.
* Works collaboratively with other departments and services to define and investigate areas of inefficiency and participates in process improvement initiatives.
* Ensures consistent data capture to identify trends/problems related to delivery of care and potentially avoidable hospital readmissions.
10. Professional Practice: Models Relationship Centered Care and Outcomes Based Care Delivery Behaviors. Consistently practices the process adapting to age-specific and cultural preferences of the patient. Demonstrates accountability/responsibility of self for completion of daily interventions/competencies.
11. Complete outbound calls by the 6 th day post hospital discharge: to assess patients' status to ensure they are receiving the recommended/required services and resources. Support patient in primary methods that will insure patient's successful post-discharge transition from hospital to home:
* Medication self-management: Patient is knowledgeable about medications and has a medication management system.
* Primary Care and Specialist Follow Up: Patient schedules and completes follow-up visit with the primary care physician and/or specialist physician and is prepared to be an active participant in these interactions.
* Knowledge of red flags and yellow flags: Patient is knowledgeable about indicators that suggest his or her condition is worsening and how to respond.
* Use and access to community resources. Patient has knowledge of where and how to obtain community resources that may be required post-discharge.
* Document interventions and maintain required statistics.
* Communicate with health care providers of Transition Call interventions through electronic medical record.
12. Maintains good rapport and cooperative relationships. Approaches conflict in a constructive manner. Guides patients toward self-identification of problems and solutions, and resolution.
13. . Maintains the confidentiality of information acquired pertaining to patients, physicians, associates, and visitors to SJMHS. Discusses patient and hospital information only among appropriate personnel in appropriately private places. Follows applicable HIPAA Privacy Rules.
14. Behaves in accordance with the Mission, Vision, and Values of SJMHS.
15. Assumes responsibility for performance of job duties in the safest possible manner, to assume personal safety and that of co-workers, and to report all preventable hazards and unsafe practices immediately to management.
16. Models the standards of care and service excellence according to SJMHS philosophy and goals and/or department guidelines.
17. Acts as a resource person for the interdisciplinary team in order to promote collaboration and coordination of transition of care considering age specific, developmental, cultural and spiritual needs of the patients
18. Recognizes and documents in 'VOICE' potential and actual areas of risk to patient safety.
OTHER FUNCTIONS AND RESPONSIBILITIES
Performs other duties as assigned.
REQUIRED EDUCATION, EXPERIENCE AND CERTIFICATION/LICENSURE
Education: Bachelor's Degree in Nursing preferred;
Registered Nurse, State of Michigan required
Current CPR Certification
Experience: Three (3) years recent experience in direct patient care as an RN with demonstrated clinical expertise or equivalent experience and expertise;
Home/Community health-based telecommunication experience desirable.
REQUIRED SKILLS AND ABILITIES
1. Competent computer skills in word processing and spreadsheet utilization. Able to use computerized medical record to retrieve and record patient information.
2. Excellent interpersonal skills to develop relationships necessary to accomplish transition calls with a wide range of patients.
3. Excellent telephonic communication skills to develop professional rapport.
4. Analytic skills necessary to assess patients' needs, and to develop, coordinate and prioritize complex interventions.
5. Excellent prioritization and organizational skills.
6. Ability to lift, bend, push, pull, sit, and stoop sufficiently. Extended physical ability to sit, write, and type.
7. Flexibility in work procedures and schedules.
This document is intended to describe the generalized duties and responsibilities, the specialized job functions, and the essential requirements of this job. It is not intended to be an exhaustive statement of all supplemental duties, responsibilities, or non-essential requirements or reflect any accommodations made under the American's with Disability Act, the Michigan Handicapper's Act, or SJMHS's Return to Work Program
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1 - 3 years of experience required
POSITION PURPOSE The Transition Support Call RN specializes in providing information and post-discharge support for the patient in identifying concerns and problems and building relationships. In this role, the Transition Support Call RN provides information and guidance to the patient/caregiver for effective care transitions, improved self-management skills and enhanced patient-practitioner communications. Call-back intervention service is based on SJMH Care Transition Program's methodology that encourages the patient to assume a more active role in their care and facilitate new behaviors and communication skills for patients to feel confident in their ability to respond successfully to common problems that arise during care transitions. This is achieved by coordinating care and service for defined patient populations during post discharge phone contact within the first post discharge week. The Transition Support Call RN works collaboratively with an interdisciplinary team to improve patient care through the effective utilization of the Health System's resources.
The Transition Support Call RN is an essential part of SJMHS Care Transitions Program. Evidence-based research supports significant benefit toward reducing System lost-revenue generated by avoidable 30-day readmissions, and significant improvement in patient satisfaction for the entire hospital episode through Transition Support Call-Back Services. The Transition Support Call RN demonstrates effective Relationship Centered service and Outcomes Based communication skills.
ESSENTIAL FUNCTIONS AND RESPONSIBILITIES
1. Assessment:
* Conducts a focused assessment as it relates to a patient's needs for transition of skill preparation.
2. Utilization Management:
* Performs assessment of intensity of service criteria for defined patient population.
3. Planning:
* Contributes to the development of age appropriate transitional plan of care through a team process that is prioritized based on medical diagnosis, patient needs, expected patient outcomes, and patient phone interaction capability.
* Ensures that all activities to facilitate and coordinate the transition plan are being implemented and that the plan is modified as needed based on patients' needs.
4. Communicates as appropriate, effectively, to:
* Guide patient towards patient's identification of needs to appropriate professionals and follows up (PCP, Specialists, Pharmacist, Therapist, Home Care staff, dietician, etc.)
* Guide patient toward maintenance of contact on a regular basis to interdisciplinary care team members: to empower patient capability of coordination of clinical activities and to enhance the effect of a seamless transition from one level of care to another across the continuum.
5. Implementation:
* Guide patients toward skill transfer of self-management to procure health system and community services and resources needed by patients and families in order to reach stated personal and health goals.
6. Collaboration:
* Serves as a resource and provides direction to patients.
* Fosters positive internal and external relationships with colleagues and associates
7. Outcomes:
* Continually evaluates Transition Support Call services and client outcomes.
8. Critical Thinking:
* Is knowledgeable about and acts in accordance with laws and procedures regarding patient confidentiality and release of information, Americans With Disabilities Act, other laws protecting rights, and workers' compensation laws when applicable to the Transition Support Call RN's practice.
9. Quality Performance/Improvement:
* Participates in the development, implementation, evaluation and ongoing revision of initiatives to improve quality, continuity and cost effectiveness of care.
* Works collaboratively with other departments and services to define and investigate areas of inefficiency and participates in process improvement initiatives.
* Ensures consistent data capture to identify trends/problems related to delivery of care and potentially avoidable hospital readmissions.
10. Professional Practice: Models Relationship Centered Care and Outcomes Based Care Delivery Behaviors. Consistently practices the process adapting to age-specific and cultural preferences of the patient. Demonstrates accountability/responsibility of self for completion of daily interventions/competencies.
11. Complete outbound calls by the 6 th day post hospital discharge: to assess patients' status to ensure they are receiving the recommended/required services and resources. Support patient in primary methods that will insure patient's successful post-discharge transition from hospital to home:
* Medication self-management: Patient is knowledgeable about medications and has a medication management system.
* Primary Care and Specialist Follow Up: Patient schedules and completes follow-up visit with the primary care physician and/or specialist physician and is prepared to be an active participant in these interactions.
* Knowledge of red flags and yellow flags: Patient is knowledgeable about indicators that suggest his or her condition is worsening and how to respond.
* Use and access to community resources. Patient has knowledge of where and how to obtain community resources that may be required post-discharge.
* Document interventions and maintain required statistics.
* Communicate with health care providers of Transition Call interventions through electronic medical record.
12. Maintains good rapport and cooperative relationships. Approaches conflict in a constructive manner. Guides patients toward self-identification of problems and solutions, and resolution.
13. . Maintains the confidentiality of information acquired pertaining to patients, physicians, associates, and visitors to SJMHS. Discusses patient and hospital information only among appropriate personnel in appropriately private places. Follows applicable HIPAA Privacy Rules.
14. Behaves in accordance with the Mission, Vision, and Values of SJMHS.
15. Assumes responsibility for performance of job duties in the safest possible manner, to assume personal safety and that of co-workers, and to report all preventable hazards and unsafe practices immediately to management.
16. Models the standards of care and service excellence according to SJMHS philosophy and goals and/or department guidelines.
17. Acts as a resource person for the interdisciplinary team in order to promote collaboration and coordination of transition of care considering age specific, developmental, cultural and spiritual needs of the patients
18. Recognizes and documents in 'VOICE' potential and actual areas of risk to patient safety.
OTHER FUNCTIONS AND RESPONSIBILITIES
Performs other duties as assigned.
REQUIRED EDUCATION, EXPERIENCE AND CERTIFICATION/LICENSURE
Education: Bachelor's Degree in Nursing preferred;
Registered Nurse, State of Michigan required
Current CPR Certification
Experience: Three (3) years recent experience in direct patient care as an RN with demonstrated clinical expertise or equivalent experience and expertise;
Home/Community health-based telecommunication experience desirable.
REQUIRED SKILLS AND ABILITIES
1. Competent computer skills in word processing and spreadsheet utilization. Able to use computerized medical record to retrieve and record patient information.
2. Excellent interpersonal skills to develop relationships necessary to accomplish transition calls with a wide range of patients.
3. Excellent telephonic communication skills to develop professional rapport.
4. Analytic skills necessary to assess patients' needs, and to develop, coordinate and prioritize complex interventions.
5. Excellent prioritization and organizational skills.
6. Ability to lift, bend, push, pull, sit, and stoop sufficiently. Extended physical ability to sit, write, and type.
7. Flexibility in work procedures and schedules.
This document is intended to describe the generalized duties and responsibilities, the specialized job functions, and the essential requirements of this job. It is not intended to be an exhaustive statement of all supplemental duties, responsibilities, or non-essential requirements or reflect any accommodations made under the American's with Disability Act, the Michigan Handicapper's Act, or SJMHS's Return to Work Program
~cb~
~mw~