Ambulatory Registered Nurse - Care Transformation - FT - Day

Transitional Care Nurse

Transitional Care Management (TCM) provides comprehensive, consultative and management services that enhance patient satisfaction, reduce costs, and improve outcomes. The Transitional Care nurse will support the organizational transitional care program by providing and interactive contact via telephone call with the patient and/or caregiver within two business days following the patient's discharge to the community setting. Using the nursing process, the TCM nurse will assess the patient's transition to home, understanding of discharge instructions, medication compliance and will direct patients to the appropriate level of care within the organizational health care system.

The TCM nurse is accountable for quality assessment, efficient managed care, and client satisfaction in collaboration with the health care team. The TCM nurse will utilize multiple IT platforms for patient identification and documentation of transitional care interventions. The delivery of professional nursing care at Stormont Vail Health is guided by Jean Watson's Theory of Human Caring and the theory of Shared governance, both of which are congruent with the mission, vision, and values of the organization.

• Bachelor's Degree Bachelor's of Science in Nursing (BSN) Preferred

• Experience in a clinic setting. Preferred
• 2 years Ambulatory or medical surgical nursing experience. Required

• Demonstrates awareness and sensitivity to rights of patient/significant other, as identified within the institution. (Required proficiency)
• Demonstrates awareness and application of safety issues as identified within the institution. (Required proficiency)
• Demonstrates awareness of legal issues in all aspects of patient care and departmental functioning. Strives to manage situations in a manner, which minimizes risk to the patient and the institution. (Required proficiency)
• Demonstrates competency in selected psychomotor skills. (Required proficiency)
• Ability to communicate effectively using verbal, non-verbal and written methods. (Required proficiency)

• Registered Nurse - KSBN A multistate license with the ability to practice within the State of Kansas is also accepted. Required
• Basic Life Support - BLS RQI, CPR or ACLS certifications may be required in lieu of or in addition to BLS depending on department. Must have within 90 days of hire.

The TCM Nurse is accountable for quality assessment, efficient managed care, and client satisfaction in collaboration with the health care team. The TCM nurse will utilize multiple IT platforms for patient identification and documentation of transitional care interventions. Formulates a prioritized and goal directed plan of care, which is based on patient's presenting problems and projected outcomes. Implements care in a knowledgeable, skillful, consistent manner, while promoting the continuum of care.

Evaluates the effectiveness of the health care process (self, systems, environment, and instrumentation) in meeting outcomes. Observes, records, and reports patient's condition and reaction to drugs and treatments to provider. The TCM nurse will ensure that the patient has an appointment with their PCP or designee within 7-14 days of hospital discharge. Documents in patient and department records in a timely, accurate and concise manner according to department standards.

Maintains and reviews patient records, charts, and other pertinent information. Compiles tests and examination results. Evaluates the patient's progress towards achieving outcomes. Performs efficiently in emergency patient situations following established standards of care. Practices effective problem identification and resolution as a method of sound decision making. Greets patients and prepares them for provider examination. Collects patient history information. Instructs patients in collection of samples and tests.

Triages and refers incoming telephone calls. Instructs patient and family regarding medications and treatment instructions. Participates in system wide/department patient care quality improvement activities as well as…