Description
RN Patient Care Coordinator
Vanderbilt Discharges and Transitions Department
2102272
Your Role:
Assists in developing and meeting key Pillar outcomes and system improvement goals including financial, satisfaction, and clinical as the nursing component of the care coordination model. This position Improves outcomes by reducing all cause hospital readmissions and coordinating episodes of care among patients in a defined population or disease process. Participates in identification of appropriate patients; encourage patient and family engagement in self-care management; promote warm handovers to the next level of care by providing timely, pertinent information in a standardized way; conduct patient and family education on key elements of the patients' personal care plan by using the teach-back methodology and follow up phone calls; and assists the patient in navigating the healthcare system.
Department/Unit Summary:
Vanderbilt Discharge and Transitions is an innovative and cutting-edge program that supports Vanderbilt University Hospital's mission. The program focuses on development, implementation and oversight of standard guidelines and innovative alternative care delivery models to ensure excellent, patient centered, and reliable care delivery for patients during time of discharge and transitions out of the hospital. The program oversees all efforts related to hospital discharge, transition of care and readmission reduction for adult patients. VDAT is a start-up, allowing the staff to set the course and culture as well as providing the opportunity to play a key role in this venture as part of Vanderbilt University Medical Center.
Shift: Full-time Days
Discover Vanderbilt University Medical Center:
Located in Nashville, Tennessee, and operating at a global crossroads of teaching, discovery and patient care, VUMC is a community of individuals who come to work each day with the simple aim of changing the world. It is a place where your expertise will be valued, your knowledge expanded and your abilities challenged. It is a place where your diversity -- of culture, thinking, learning and leading -- is sought and celebrated. It is a place where employees know they are part of something that is bigger than themselves, take exceptional pride in their work and never settle for what was good enough yesterday. Vanderbilt's mission is to advance health and wellness through preeminent programs in patient care, education, and research.
Our Nursing Philosophy:
We believe highly skilled and specialized nursing care is essential to Vanderbilt University Medical Center's mission of quality in patient care, education and research. We believe nursing is an applied art and science focused on helping people, families and communities reach excellent health and well-being.
Achieve the Remarkable:
Learn more about VUMC Nursing:
KEY RESPONSIBILITIES:
- Coordinates the evaluation process of the defined patient population. May complete and document portions of the evaluation process, collaborating with other team members to ensure completion of all required information.
- Supports patient access by serving as a liaison between the referring provider's office and Vanderbilt provider.
- Interacts routinely and effectively with the clinical team to develop a collaborative plan for the coordination of patient care from the anchor hospitalization through the defined care episode.
- Develops and manages the processes related to pre-admission and post-discharge care transitions; establishes relationships/clinical pathways with providers/agencies to optimize care for defined patient population.
- Assists in the development and dissemination of patient education materials/information to include creation of customized medication grids with input from the pharmacist/team as needed.
- Assists with discharge/transition planning in collaboration with the multi-disciplinary team, actively engaging outpatient care providers by sharing hospital course, concerns, pending test results, learning needs, partnership opportunities etc. Coordinates handovers including outpatient care coordinators (disease management teams), home health care nurses, cardiac rehab, skilled nursing facilities, etc.
- Demonstrates reflective practice by constantly evaluating care coordination and supports the development of protocols for practice based on evidence
- The responsibilities listed are a general overview of the position and additional duties may be assigned.
