Transitional Care Nurse

About Us

Signature Health

CARE of East Louisville is a 128-bed facility offering long-term care facility is noted for its Center for Advanced Diabetes Care, inpatient and outpatient rehab, in-house dialysis, wound care, as well as 24-hour skilled nursing care for recently hospitalized and chronically ill patients. It is our mission as a family-based organization to revolutionize the healthcare industry through a culture of resident centered healthcare services, personalized spirituality, and real quality of life initiatives.

Signature Health

CARE is a family-based healthcare company offering integrated services across multiple states. Our continuum of care includes skilled nursing, rehabilitation, assisted and memory care, and home-based services supported by innovative technologies like telehealth and Care.ai-enabled solutions.

We are committed to advancing person-directed care and quality outcomes. Many of our facilities continue to receive high performance ratings and accreditations. As an award-winning organization recognized over the years by national outlets such as U.S. News & World Report, we take pride in fostering compassionate care environments and being an employer of choice in the healthcare industry.

Overview

Coordinate the smooth transition of resident from various care settings to improve the overall customer experience and reduce re-hospitalization.

How you Will make a difference

* Identify and participate in process improvement initiatives that improve the customer experience, enhance work flow, and/or improve the work environment.

* Understand and assist in coordinating the Transitional

CARE program within the facility.

* Communicate with clinical nurse and review hospital accepted referrals to identify immediate needs and overall clinical status of the patient.

* Review current medications of the patient from the hospital.

* Obtain clinical report from the hospital nurse prior to transition.

* Brief the primary care team, nurse, CNA, and Nurse Practitioner (NP), prior to admission.

* Ensure that all necessary equipment and medications are available prior to patient arrival.

* Collaborate with clinical liaison and admission team to assist with completion of the nursing Transitional Readiness Form.

* Reconcile all medications (home and hospital) with the current physician orders.

* Review and manage medications related to current formulary and corroborate with the attending physician.

* Review Advance Care Planning with the patient and family.

* Lead the Full Life Conference within twenty-four (24) business hours of admission.

* Coordinate the transitional home planning with social services within twenty-four (24) business hours of admission.

* Start the personal health record (PHR) and coordinate with NP.

* Conduct coaching sessions related to the PHR prior to transitioning home.

* Coordinate with the MDS coordinator the overall plan of care of the patient within the first twenty one (21) days.

Develop and conduct patient/family teachings on chronic disease management (CHF, COPD etc.).

* Conduct clinical rounds with the primary care team and the NP within twenty four (24) business hours of admission.

* Conduct daily clinical rounds of all patients in the transitional care unity to ensure positive patient experience.

* Conduct transitional counseling within twenty-four (24) business hours of admission, as requested.

* Notify the primary care physician upon admission.

* Notify primary care physician of transition and schedule the first physician visit after discharge from the facility.

* Review and reconcile the PHR with the patient and family prior to discharge.

* Conduct weekly follow-up phone calls to review clinical status, etc. after discharge with the patient and family for the next thirty (30) days.

* Conduct Stakeholder in-services related to chronic disease management.

* Collaboratively work with the MDS coordinator related to current clinical condition and plan of care.

What you Need to make a Difference

* Bachelor's degree in nursing required or actively working towards obtaining;
Master's degree in nursing preferred.

* Licensed Practical Nurse (LPN) or Registered Nurse (RN) in good standing with…