Registered Nurse - Transition Coordinator - Henry Ford at Home - Full Time - Days

PRINCIPLE DUTIES AND RESPONSIBILITIES:

 Independently participates in the clinical assessment, problem identification, and planning functions for patients who have been identified by the case management team, other health care facility personnel, physicians, or patients/families as possibly needing Henry Ford at Home products and services.

Uses clinical assessment skills to determine the patient’s appropriateness for Henry Ford at Home services by reviewing the patient’s medical condition as well as the patient’s and caregiver’s potential ability to assist with aspects of the care plan, performing an assessment identifying required community services, and communicating the needs with the physician and other appropriate individuals.

Collaborates and communicates with Henry Ford at Home leaders and staff to ensure appropriate and timely referrals. Performs patient and family education prior to start of care; provides information and education to patients and families prior to discharge.

Interprets diagnostic data and incorporates data into the assessment. Assess health problems/perceptions of the client and or family andclient’s expectations.

Collaborates with referral sources to identify problems and resolutions.

Coordinates patient discharge with hospital/facility case managers, including patient and/or family and other members of the health care team.

Determines appropriate frequency of nursing visits/duration based on patient needs when applicable.

Reviews and remains updated on knowledge of Henry Ford at Home criteria,

Medicare conditions of participation, 3rd party payer information and CHAP guidelines.

Acts as a consultant and subject matter expert to the health care facility staff, patients, caregivers and the community for information regarding various aspects of Henry Ford at Home products and services.

Coordinates and assists hospital/facility case managers in ensuring a smooth transition for patients from the inpatient setting and physician office.

Assist referral sources in problem identification and develop solutions to improve the referral and case management process.

Evaluate and document the effectiveness of the nursing intervention; monitor other clinical QA indicators as assigned.

Assists with research, record keeping, scheduling, and communicating. 

May assist patients, home care nurses and home infusion staff in trouble shooting infusion related problems (pumps, IV access, etc.) as needed.

Provide on-going home care information and education to physicians, case managers, and other referral sources.

Serve as clinical needs consultants to CM’s and medical staff, and advisors to same in cases with special circumstances surrounding patient’s family and home environments.

Serve as specialty program coordinators such as with Advanced Home Health and Safe at Home programs.

May initiate, develop and implement nursing plan of treatments; evaluate patient progress towards goals.

Organizes and participates in the provision of direct patient care, performs treatments, and educates patients and families/caregivers as needed. May administer medications.

Appropriately modifies plan of treatment in response to changing patient status or physician orders to achieve established or revised patient care goals. Re-evaluates patient needs through physical reassessment, response to therapy, and supplemental physician orders.

Obtains and clarifies physician orders for plan of treatment revisions, informs physician promptly of significant changes in patient's condition, and provides written summary to physician within supplemental order.

Provides effective and safe teaching using patient-centered care approach for patient and family to achieve independence with prescribed therapy and care needs through active participation per plan of treatment goals.

Prepares clinical documentation in real-time during visits and submits to comply with established timelines for billing optimization as needed.

Assist Admission/Billing departments with reauthorizations as needed.

Demonstrates compliance with Henry Ford at Home policies and procedures, professional standards, local, state, federal regulations/guidelines, and accreditation standards.

Maximizes work efficiency using computers and other automation technologies to validate plan of treatment orders, communicates patient care provided, and follows assigned visit schedule.

Responds promptly and appropriately to patient requests. Initiates emergency procedures as necessary.

Participates in multidisciplinary team conferences and may provide mentoring to other clinical staff for orientation and supervisory activities as assigned. Participate in process improvement and quality teams.

 Perform other related duties and projects as assigned.