RN Patient Care Coordinator - Pediatric Heart Institute

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Organization:

CHOC Ped Heart Institute

Job Summary:

Assists in developing and meeting key Pillar outcomes and system improvement goals including financial, satisfaction, and clinical as the nursing component of the care coordination model. This position Improves outcomes by reducing all cause hospital readmissions and coordinating episodes of care among patients in a defined population or disease process. Participates in identification of appropriate patients; encourage patient and family engagement in self-care management; promote warm handovers to the next level of care by providing timely, pertinent information in a standardized way; conduct patient and family education on key elements of the patients' personal care plan by using the "teach-back" methodology and follow up phone calls; and assists the patient in navigating the healthcare system.

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Monroe Carell Jr. Children’s Hospital at Vanderbilt's Pediatric Heart Institute is a national leader in the care of children with heart-related conditions.

Our team of fetal cardiologists, general cardiologists, electrophysiologists and cardiac surgeons, and the large group of health care experts who support them, diagnose and treat children with minor to complex heart differences.

While children are still in the womb, throughout their childhood and through adolescence, we work closely with families and doctors to ensure personalized care specific to the needs of every child we treat.

KEY RESPONSIBILITIES
• Coordinates the evaluation process of the defined patient population. May complete and document portions of the evaluation process, collaborating with other team members to ensure completion of all required information.
• Supports patient access by serving as a liaison between the referring provider's office and Vanderbilt provider.
• Interacts routinely and effectively with the clinical team to develop a collaborative plan for the coordination of patient care from the anchor hospitalization through the defined care episode.
• Develops and manages the processes related to pre-admission and post-discharge care transitions; establishes relationships/clinical pathways with providers/agencies to optimize care for defined patient population.
• Assists in the development and dissemination of patient education materials/information to include creation of customized medication grids with input from the pharmacist/team as needed.
• Assists with discharge/transition planning in collaboration with the multi-disciplinary team, actively engaging outpatient care providers by sharing hospital course, concerns, pending test results, learning needs, partnership opportunities etc. Coordinates handovers including outpatient care coordinators (disease management teams), home health care nurses, cardiac rehab, skilled nursing facilities, etc.
• Demonstrates reflective practice by constantly evaluating care coordination and supports the development of protocols for practice based on evidence
• The responsibilities listed are a general overview of the position and additional duties may be assigned.

TECHNICAL CAPABILITIES
• Evidence-Based Practice (Advanced): Recognizes, Implements, and evaluates practice changes based on published research. Demonstrates expertise in applying evidence-based practices to challenging and complex situations.
• RN Access Patient Education (Advanced): Demonstrates uppermost levels of patient education in practical applications of a complex nature. Possesses mastery of knowledge, training, and expertise to be capable of successfully delivering treatment planning services across the care continuum. Takes a lead role in complex situations when there is a need to achieve results. Actively participates in outside professional organizations and forums.
• Nursing Patient Assessment & Evaluation (Advanced): Demonstrates the uppermost level