RN Transitional Care Nurse-Cerebrovascular Program

Job Description Summary

The Transitional Care Nurse (TCN) in the Outpatient Cerebrovascular Program reports directly to the Stroke Program Director and works collaboratively with the Comprehensive Cerebrovascular Medical Director and Stroke Clinic Nurse Practitioner(s). This role is essential in providing transitional care to stroke patients and their families, ensuring care continuity from acute hospitalization to rehabilitation and integration into the outpatient stroke clinic. Position is Full-time, M-F, business hours.

Entity

Medical University Hospital Authority (MUHA)

Worker Type

Employee

Worker Sub-Type​

Regular

Cost Center

CC000684 CHS - Stroke Program (Main)

Pay Rate Type

Salary

Pay Grade

Health-29

Scheduled Weekly Hours

40

Work Shift

Standard Day (United States of America)

Job Description

Position Overview: The Transitional Care Nurse (TCN) in the Outpatient Cerebrovascular Program reports directly to the Stroke Program Director and works collaboratively with the Comprehensive Cerebrovascular Medical Director and Stroke Clinic Nurse Practitioner(s). This role is essential in providing transitional care to stroke patients and their families, ensuring care continuity from acute hospitalization to rehabilitation and integration into the outpatient stroke clinic.

Schedule:

Full-Time (40 hours/week)

Monday-Friday

Business Hours

Key Responsibilities:

Transitional Care Delivery:

• Coordinate and deliver follow-up care via phone or webcam to stroke patients, assessing their medical conditions, functional status, and addressing new health issues.
• Review and manage medications, coordinate follow-up appointments, and connecting patients with necessary studies and community resources.

Education & Support:

• Serves as an educational resource to patients and families regarding stroke prevention, rehabilitation, and recovery.
• Provides patient/family education on stroke-related topics such as prevention medications, stroke rehabilitation, and lifestyle modifications.
• Assist patients and families with stroke recovery by facilitating support resources and providing clear guidance on recovery plans.

Collaboration & Coordination:

• Work closely with interdisciplinary teams, including vascular neurology, neurosurgery, neuroendovascular surgery, nurse case management, social services, smoking cessation counselors, dietary services, and community organizations.
• Ensure coordinated care by scheduling and tracking patient appointments, tests, and follow-up appointments with specialists.
• Address patient needs related to appointments, imaging, and testing, while also coordinating with outside institutions to retrieve medical records when needed.
• The TCN RN enjoys autonomy in managing and facilitating the care of stroke patients, while still being supported by a collaborative and interdisciplinary healthcare team.

Care Continuity:

• Ensure patients have access to essential services, from acute hospitalization through community integration (support groups, financial assistance, disability resources, etc.).
• Address social determinants of health, assisting patients with referrals to community services and overcoming barriers to healthcare access.

Triage & Communication:

• Manage patient care inbox messages, return patient calls, and triage concerns as needed.
• Conduct follow-up phone calls, including 2-day discharge calls, 7-day complex calls, and 90-day functional assessments (mRS scoring).

Program & Event Participation:

• Participate in stroke community events and represent the MUSC Comprehensive Stroke Program.
• Engage in educational opportunities, including care team education and stroke certification surveys.

Documentation & Reporting:

• Maintain accurate documentation of patient care, education, and follow-up, ensuring compliance with program standards.
• Contribute to program data tracking and quality improvement initiatives within the stroke program as needed.

Requirements (Education, Work Experience, Licensure, Registry &/or Certifications)

Qualifications for Transitional Care Nurse – Outpatient Stroke Clinic

• Education:
  • Bachelor of Science in Nursing (BSN) degree from an accredited college or university.
  • Alternatively, a Master of Science in Nursing (MSN) or Doctor of Nursing Practice (DNP) in lieu of a BSN.
• Work Experience:
  • A minimum of two to three years of experience in nursing, preferably in a clinical s