Transition Nurse Navigator - Heart Failure Program

Scope of Position / Position Summary

The Heart Failure (HF) Program Care Navigation Liaison improves outcomes by reducing all cause readmissions and coordinating episodes of care among patients in a defined population or disease process. The primary focus is on the coordination and delivery of efficient, effective, compassionate, patient centered care and safe transitions across the care continuum. The HF Program Care Navigation Liaison monitors the patient care process and physiological needs;

educates, documents, communicates, and collects data to evaluate and assure patient/family readiness for discharge. The HF Program Care Navigation Liaison facilitates the lateral integration of the care team, collaborating with physicians, nurses and other staff across the continuum to provide comprehensive disease management, assessment, treatment, education, and follow‑up evaluation for patients; and to communicate the plan of care in coordination with post‑acute care settings.

The HF Program Care Navigation Liaison ensures a fluid integration of all willing patients discharging with a primary diagnosis of HF and are followed for Care Navigation services in the ambulatory space and serves as a liaison with post‑acute partners including, but not limited to, CVS, Wellsky, and others as determined by the HF Leadership team.

• Serves as a liaison to ensure enrollment of appropriate HF patients with post‑acute partner organizations
• Communicates with post‑acute partners on HF patient care plans as needed
• Coordinates the evaluation process of the HF patient population, may complete and document portions of the evaluation process, collaborating with other team members to ensure completion of all required information
• Is a liaison between the medical team, staff nurses, consult teams, ancillary staff, Ambulatory Care Navigation services, PCP, and patients; coordinates ancillary consults and suggests possible patient needs including PT, OT, cardiac rehab, palliative care, and social services
• Reviews medical team documentation and consults as a basis for intervention
• Develops and manages processes related to pre‑admission and post‑discharge care transitions
• Establishes relationships/clinical pathways with providers/agencies to optimize care for the defined patient population
• If the patient is identified in an acute care setting as high risk, may perform or consult for face‑to‑face assessment of the patient; if a readmission, RN collaborates with IP Case Manager and conducts a patient interview to review possible causes
• May participate in attending rounds to fully understand the plan of care, provide decision support and focus the team on the expected course of disease management
• Develops and proactively consults for or modifies a care plan with the medical team for each patient by assessing educational needs in conjunction with caregivers; communicates plan to the patient and facilitates patient adherence
• Interacts with consulting physicians, HF Program Lead APP, and other health care providers internally and externally to assure the progression of the plan of care and externally to facilitate follow‑up care
• Consults for and acts as liaison with multidisciplinary care conferences including ethics discussions, develops concise patient care plans for use by the team, and documents recommendations made utilizing standardized care protocols in accordance with nationally recognized care guidelines; provides information about past hospitalizations and known contributing factors to readmission
• Collaborates with and assists case managers in discharge planning, identifying outpatient needs and follow‑up care, and arranging for discharge prescriptions
• Manages patient progress post‑discharge by ensuring patient follow‑up appointments, tests, and procedures are noted in the After Visit Summary (AVS)
• For patients requiring additional Care Navigation services beyond the first 30 days post‑discharge, contacts patients within an established timeframe and at designated intervals to assess patient status, answer questions, provide education, and facilitate communication with…