Nurse Navigator - Cystic Fibrosis Clinic

Overview

Nurse Navigator - Cystic Fibrosis Clinic at Hartford Health Care

Location: 79 Retreat Ave HH Brownstone (10065).
Shift: Weekdays.
Work Location Type: In Person.

Hartford Health Care is a Connecticut-based healthcare network committed to improving health and healing for the people and communities we serve.

Functioning within the framework for professional nursing practice, the Cystic Fibrosis Clinic Nurse Navigator is a registered nurse experienced in patient throughput, preventing transitional care gaps, and resolving issues to enhance the quality and continuity of a patient’s or populations health care leading to improved health outcomes and equitable care. Under provider direction, the Nurse Navigator provides skilled nursing care to patients in a variety of clinical settings.

This position reports to a Nurse Manager.

• Functions as a member of an interprofessional care team in an expanded nurse role to help patients transition from the acute care setting (HH ED or inpatient). Goals include reducing all-cause readmissions and inappropriate ED utilization, improving care coordination during transitional care, and improving care quality and access for vulnerable populations. Educates the Hartford Health Care community and advocates for resources to enhance patient healthcare engagement and collaboration among inpatient, ambulatory, outpatient, attending, transitional care, specialty care, and primary care teams for high risk/complex patients.
• Partners with inpatient or ED physicians and care teams to proactively identify transitional care gaps and establish a safe transition plan, including scheduling urgent CF Clinic appointments with transportation, ensuring necessary DME, finalizing a community medication plan, completing diagnostic workups, patient education on disease and symptom management, and incorporating a patient-centered home care plan.
• Performs post-hospitalization/ED transitional care strategies within 24-48 hours after discharge, including post-discharge calls, education, symptom management, and medication reconciliation; collaborates with CF clinic physician and care teams to minimize identified gaps in care.
• Facilitates completion of diagnostic workups, follows up on unresulted diagnostics, and collaborates with homecare, pharmacy, and DME to ensure supplies and medications; obtains authorizations and schedules additional consultant appointments.
• Collaborates with clinic physicians to resolve issues and advance the treatment plan until an established primary care provider is in place.
• Assists the patient in identifying a primary care practice for continued care and facilitates the transfer of care to that practice, in collaboration with the CF Clinic physician.
• Documents all communication, transition plans, strategies implemented, and patient outcomes in EPIC.
• Establishes a therapeutic rapport with patients and serves as a patient advocate; works independently and with the care team to provide safe, efficient patient care; shares transitional care strategies with peers and patients as needed.
• Attends care team meetings to facilitate safe transition plans and resolve patient issues; establishes evidence-based standard work and workflows; develops processes to improve the patient experience and analyzes data to identify opportunities for improvement.
• Applies the nursing process within the organization’s framework and follows guidelines established by the team; provides office-based nursing care in collaboration with the provider, communicates nursing assessments and recommendations, and demonstrates independent nursing actions as appropriate.

• BSN required, MSN preferred
• Minimum five (5) years of nursing experience; inpatient and ambulatory experience preferred
• Current Connecticut Nursing License
• BLS Certification

As an Equal Opportunity Employer/Affirmative Action employer, Hartford Health Care will not discriminate in its employment practices due to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran status, or disability status.