RN, Heart Failure Program Coordinator

The Heart Failure Nurse Coordinatorisresponsible for coordinating the comprehensive specialized care for patients withinour Advanced Heart Failure Program, both in the inpatient and the outpatient setting. The coordinator collaborates with the health care team and provides leadership in achieving standards of care, including on-going quality and evidence-based practice to ensure process efficiencies.

This role also provides formal and informal program education within facilities as is relevant, and collaborates with facility administration, medical directors, nursing staff and community partners in order to assure process improvement for the care of the advanced heart failure patients. Through knowledge and experience, the Heart Failure Nurse Coordinator should have the skill set to coordinate and oversee the patient care of this high-risk patient population throughout the continuum and can organize and interpret trends in registry data points and focus on continually improving patient outcomes.

The Heart Failure Nurse Coordinator can support professional knowledge and healthcare management through effective interactions and communications with clinicians, health care administrators, community agencies and other professionals.

As an administrator, the Heart Failure Nurse Coordinator is responsible for overseeing internal staff education and competencies and for serving as a resource to all nursing areas for the care of this patient population.

The Heart Failure Nurse  Coordinator supports the Heart Failure program in delivering preventive, primary and acute healthcare services to adults with heart failure; provides education that aligns with standards and evidence based research,; contributes to new knowledge and/or technology bysupportingor participating in research; and, supports quality improvement efforts in the heart failure program through evidence-based practice, regulatory standards, national registry participation and service line activities.

Assure the safe, efficient, high quality and customer-oriented management of patient care to identified patient populations; provide health teaching with an emphasis on prevention of illness and health maintenance as needed to supplement the standard of care; and, perform care coordination for patients tosupport them through their healthcare journey.

Performseducation and coordination of careforhigh-risk patients asdeemedappropriate (inpatient,and inclinics when appropriate). Collaborates with internal and external clinicians and agencies to coordinate transitions of care for patients with heart failure. Specifically provides the following:

• Inpatient rounding and surveillance of patients admitted with heart failure diagnoses.

• Providesindividualizedinpatient heart failure patient education for select patients (based on needs assessment and heart failure program definition)

• Supportsa patient-centered care plan in partnership with the care team.

• Collaborates with care teamto provideguideline directedheart failure care

• Works withinpatientteams tooptimizetransitions of care from inpatient to outpatient

• Enhanceshealthcare team/provider and patient communication in discharge planning and care transitions to reduce hospital readmissions among patients with heart failure

• Supports inpatient teams in securingheart failurehospital follow upvisitsandtimelyreferrals to heart failure specialist as appropriate

• Completes hospital discharge follow up phone calls for patients admitted with heart failure

• Demonstrates knowledge of social determinants of healthand barriers to implementationofappropriateheartfailuremanagementin partnership with the care team.

• Applies culturally sensitive methodswhentransitioningheart failurepatients from…