Care Transition Nurse - LPN (PRN)

Responsibilities

• Collaborates with members of the multidisciplinary team to facilitate successful transitions to the home setting post discharge.
• Prioritizes follow up of the patient's care needs and referrals according to established criteria and levels.
• Provides appropriate referrals to sub-acute levels of care and physicians based on identified needs of the patient.
• Provides support and education to all patients/caregivers in disease management addressing critical issues and treatment.
• Evaluates the patient/family knowledge based on developmental needs and assessment of the specific population being addressed.
• Recognizes each of the following aspects of patient's condition: diagnosis, medications and support systems.
• Utilizes critical thinking skills in achieving successful outcomes related to disease/medication management.
• Responsible for assisting in the coordination of discharge planning including primary care/specialty follow-ups, clinic appointments and SBAR communication with referral agencies post discharge.
• Supports and promotes patient self-management and empowers patients/families to achieve maximum levels of wellness and independence.
• Communicates critical information related to risk issues or other need to know information with RN Coordinator, administration, risk management, medical management, medical staff and patient advocates.
• Documents interventions and encounters in a timely and thorough manner in appropriate areas of the chart.
• Data/Measurements
• Collects and maintains specific databases on care transition population.
• Completes data input timely and accurately.
• Participates in measuring clinical outcomes and data procurement.
• Represents the care transition program on performance improvement teams as requested.
• Collaboration and Partnership
• Consistently communicates/ collaborates with patients/caregivers and identified sub-acute providers to maximize patient outcomes.
• Communicates, collaborates with community resources to meet specific patient needs and to enhance patient outcomes.
• Maintains knowledge regarding program initiatives based on geriatric population/needs and incorporates the outcomes into practice.
• Critical Thinking
• Applies LACE to determine the transition care needs of the patient.
• Identifies/consults available resources to meet patients' identified transition needs.
• Aids the patient/family/caregiver in the management of complex health issues to improve health outcomes utilizing education and available resources.
• Understands personal limitations and further assistance when needed in the care needs of the patient.
• Collaborates with all multidisciplinary team members to coordinate and assure continuity of care and assist in meeting the patient's individualized plan of care post discharge.
• Effectively communicates with community providers information and needs of the patient requiring further follow through with in the home environment.
• Provides ongoing support to patients following discharge, through telephone calls and assistance with community resources.
• Provides assistance with obtaining post-discharge a primary care provider and/or specialist based on patient's needs and financial limitations for continued long term care needs.
• Provides education to the patient and family/caregivers in medication self-management, use of a personal health record, knowledge of disease management and potential problems that may need further intervention.

Qualifications

• 3 years clinical experience.
• Graduated from a Practical Nursing School program.
• NICHE GRN Certification (required within six months).
• Proficient in English, verbal, written Communication and computer skills.
• Current unrestricted Louisiana LPN license.
• CPR Certification.