Adheres to the nursing care Scope of Practice and Care Management Scope of Service in achieving the goals of the Care Transitions Team.
Applies appropriate criteria to identify patients who are at high risk for readmission or for high emergency room utilization. Follows up with patients at location of post discharge transfer. Conducts patient and family education, utilizing Teach Back method. Incorporates patient, physician, and customer needs and concerns into decision-making and organizational action. Identifies gaps in service that prevent the patient from achieving increased stability in daily living.
Prioritizes clinical problems, formulates treatment goals, and constructs treatment plan, revising as needed, based on continuous evaluation and assessment of progress. Quickly appraises crisis situation and selects appropriate intervention(s). Mediates highly complex situations and develops treatment plans with minimal supervision. Acquires working knowledge of motivational interviewing and working with resistant clients.
Documents in patient's medical record after each significant contact and at closure of case.
Evaluates practice upon completion of case intervention, determining whether intervention was successful and whether client achieved expected outcome. Seeks appropriate consultation. Admits mistakes openly and seeks ways to resolve issues. Creates a safe environment for honest and open communication.
What Will You Need:
EDUCATION AND EXPERIENCE REQUIRED:
Bachelor of Science in Nursing (BSN)
Two years of experience in acute care hospital discharge planning
One year of Experience Nursing, Case Management, and/or Social work
EDUCATION AND EXPERIENCE PREFERRED:
Master of Science in Nursing (MSN)
Three years of experience in acute care hospital discharge planning
Experience in outpatient or home health setting and critical care
LICENSURE, CERTIFICATION, OR REGISTRATION REQUIRED:
Basic Life Support (BLS) OR ACLS (Advanced Cardiac Life Support) certification
LICENSURE, CERTIFICATION, OR REGISTRATION PREFERRED:
Case Management certification - Accredited Case Manager (ACM)
Certified Case Manager(CCM)
The Care Transitions Registered Nurse ensures that a care plan is carried out in partnership with the person at the center of the care plan. Works as part of the interdisciplinary Care Transitions Team to implement the AdventHealth's readmission prevention programs, which are targeted to reduce the number of patients who are readmitted to the hospital. Follows selected patients that transition from the hospital to a lower level of care. Participates in routine readmission meetings with community partners as well as complies with data collection expectations. Works as part of various other teams, including but not limited to Care Management nurses and social workers, nursing, home care liaisons, physicians, pharmacists, dietitians, and leadership. Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all.
This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.
AdventHealth Greater Orlando (formerly Florida Hospital) is one of the largest faith-based health care providers in the United States. For 150 years, we have carried on a tradition of providing whole-person care that not only addresses patients' physical ailments, but also supports their emotional and spiritual well-being. We demonstrate the same level of compassion and care for our employees as well, doing all that we can to help them realize their full potential – both personally and professionally.