Job Overview 

This position, in conjunction with Case Management, coordinates the transition of care from one health care setting to another which includes:  inpatient, Home Health Care, Skilled Nursing Facility, Rehab facilities.  Educates the patient and /or family regarding the patient's clinical condition, treatment, postoperative course, and the patient's role in recovery. Collaborates and communicates with a wide range of multidisciplinary providers with the goal of achieving an exceptional patient experience and the best possible patient outcomes.   

Job Description 

Duties and Responsibilities: The duties and responsibilities listed below are intended to describe the general nature of work and are not intended to be an all-inclusive list.  Other duties and responsibilities may be assigned. 

Inpatient Care

• Identifies eligible inpatients using established program criteria
  • Delivers education to the patient and caregivers, including teach back interventions
  • Performs risk assessment using standardized tool
  • Supports non-cardiology primary providers with HF guideline directed medical therapies plan, including liaising with pharmacy

Transitions of Care

• Collaborates with other members of inpatient care team to develop discharge care plan
  • Coordinates post-discharge care to ensure seamless transition
  • Collaborates with pharmacist on medication reconciliation
  • Schedules post-discharge clinic appointments 
  • Communicates with patient’s PCP and post-acute care providers regarding post-discharge care expectations
  • Develops a plan for scheduled check-ins with patients and caregivers

Post-Discharge Care

• Calls patient by phone at pre-determined intervals
  • Ensure patient adherence with care plan (e.g., medications, self-monitoring)
  • Communicates closely with the patient and their family during the first 30 days post-discharge to ensure they are fully informed and supported during the transition period
  • Reminds patients of upcoming appointments
  • Helps resolve obstacles to adherence and wellbeing

Data Collection

• Collects and documents key data points into appropriate systems (e.g., risk assessment score)
• Helps provide QA of appropriate systems to ensure data integrity
• Performs interval reviews of readmission cases to identify opportunities for improvement

Program Development

• Recommends improvements or development of standards of practice for inpatient, post-acute, home and ambulatory care of patients
• Participates in the development and evaluation of program tools and interventions, such as patient education materials, risk assessment tools, and databases
• Provides educational in- and outreach to providers in the network
• Works in collaboration with heart failure disease management NP and RN

Qualifications

• Bachelor of Science degree in Nursing
• Registered nurse with current unrestricted Massachusetts state license
• Heart failure nurse certification highly desirable
• Minimum of 5 years of clinical nursing experience working with heart failure cardiology patient population