RN Care Facilitator, Ed BWH

Site:
The Brigham and Women's Hospital, Inc.

Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.

Job Summary The Emergency Department Care Facilitator (EDCF) proactively coordinates patient care in a fast-paced emergency department setting utilizing clinical assessment skills to identify patient needs, coordinate care, manage utilization, and support safe transitions of care while supporting patient flow and throughput from the emergency department. The EDCF serves as a key partner to ED physicians, nurses, the interdisciplinary team, and community partners and resources to support timely, appropriate care decisions.
· Collaborates with ED providers and care teams to assess patient needs upon presentation.
· Facilitates patient transfer of care and communicates care plans to referral sources, receiving providers, and support resources.
· Participates in the ongoing evaluation of practice patterns and systems, and supports efforts to improve quality, cost of care, and satisfaction outcomes.
· Mobilizes resources to maximize efficiency of care delivery and quality of care in accordance with regulations and hospital policy and procedures.
· Maintains a flexible work schedule to match availability to patient demand.

PRINCIPAL DUTIES AND RESPONSIBILITIES:

Indicate key areas of responsibility, major job duties, special projects and key objectives for this position. These items should be evaluated throughout the year and included in the written annual evaluation.

A. Care Facilitator Coordinates and ensures implementation of the plan of care, utilizing case management principles

Participates in processes to facilitate transition of care and identifies opportunities for improved utilization of care delivery resources to meet patient needs.

Upon presentation to the ED, collaborates with the interdisciplinary care team to assess care needs and determine needs for discharge support and/or transition of care.

Presents alternative care delivery sites to ED providers, and the patient and family when appropriate.

Reviews patients past medical history and current treatment plan with ED providers to ensure optimal coordination and resource utilization.

Participates in ED patient rounds to identify and contribute to case finding opportunities for improved coordination of care and high-risk patient identification.

Communicates high risk patient’s needs and follow-up plans of care to community-based and/or hospital-based care coordinators.

Forms and maintains relationships with community-based providers to enhance transition of patient care between the ED and the community.

Incorporates knowledge of emergency medicine, utilization management, and community providers into patients' plan of care, and informs ED providers of implications and opportunities.

Assesses needs for continuing care in conjunction with patient’s family and/or caregivers.

Initiates contact with patient transfer and access department and/or other acute care hospitals, post-ED care facilities, and home health agencies to ensure prompt transitions of care.

Facilitates all discharge plans requiring post-ED care. Works in partnership with the ED social workers and staff nurses to facilitate transition of care.

Participates in decision to admit patients to determine appropriateness of admission and prevent unnecessary admissions.

Iden…