Care Transition Nurse - LPN (PRN)

What Makes Us Different?

At FMOLHS, we offer you so much more than just a job in the healthcare industry. We offer career opportunities for people who have a calling to share their gifts and talents as part of our healing ministry. As a Catholic hospital, we are here to create a spirit of healing. We offer you something special - the chance to do God's work by helping to serve people in need throughout our community, every day.

Job Summary

The transitional care nurse works with members of the multidisciplinary team and the patient/caregiver to ensure that an effective and well-informed discharge occurs.  The nurse will function as a liaison between the acute setting and sub-acute levels included, but not limited, to home health, nursing home, hospice care and/or family caregiver. The Transitional care nurse provides continued education post discharge to the patient/family members to promote positive outcomes and ensure understanding of disease, prevention and treatment modalities utilized. The nurse provides resources to the patient/caregiver necessary to meet the specific identified needs of the patient. The nurse collects, inputs and maintains specific data necessary for the completion of specific dashboards which are utilized to enhance and coordinate the needs of the population served. In conjunction with the RN coordinator, the Transition of Care nurse reviews and discusses findings/concerns in relationship to the established plan of care for further evaluation and assistance.   The nurse is responsible to complete all NICHE GRN education and continue participating in geriatric nursing education programs to maintain knowledge base. The Transition nurse behaves in a professional manner, and consistently demonstrates and promotes the values of respect, honesty, care, and dignity for the patient and all members of the healthcare team. The Transition of Care nurse is committed to the constant pursuit of excellence in improving the health status of the population followed.

Minimum Requirements

Experience - 3 years clinical experience.

Education - Graduated from a Practical Nursing School program.

Special Skills - Proficient in English, verbal, written Communication and computer skills

Licensure - Current unrestricted Louisiana LPN license CPR Certification.

Apply now! Here, you are more than an employee. You are a team member, a co-worker, our friend and part of our family. Our healthcare team is working together to heal this community one patient at a time!

 1.   Technical Tasks

• 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.
• As a member of the multidisciplinary team, works to obtain resources for high-risk patients for readmission related to inadequate family support, poor understanding and social restrictions. Notifies and discusses findings and concerns with attending physicians and provides possible suggestions for additional support, i.e. Geriatric Medical Clinic, Transitional Care Clinic, Council of Aging, Elderly protection, etc.
• Documents interventions and encounters in a timely and thorough manner in appropriate areas of the chart.

      2.   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 i