POSITION SUMMARY

The Transitional Care Nurse will be responsible for managing KU Internal Medicine patients’ transition process from inpatient hospital care to outpatient care. Outpatient care includes discharges to intermediate and temporary care facilities including, but not limited to, KU MPA ambulatory care clinics, skilled nursing facilities (SNF), nursing homes, long-term care facilities (LTCF), and assisted living facilities. Inpatient care will be provided at Ascension Via Christi St. Francis (AVCSF) Hospital and Wesley Medical Center (WMC). It is expected the NTCC would round between one or both hospitals (as assigned) and work with the patients’ respective medical team and ancillary teams to coordinate each patient’s transition of care.

ESSENTIAL FUNCTIONS:

General Responsibilities:

• Identify patients eligible for Transitional Care Management (TCM) and enroll appropriate patient’s into TCM programs.
• Work with KU Internal Medicine (IM) Hospitalist providers to identify patients who are not eligible for TCM but require ongoing follow-up care coordination through KU IM or GI clinics.
• Monitor all aspects of patient care including diet, physical activity, medication accessibility/afford-ability, and care coordination.
• Work with patients, groups, or families to plan or implement safe and effective transitions of care plans.
• Schedule and confirm appointments for patients by coordinating with clinic office staff, ancillary providers, and primary care providers.
• Determine best level of outpatient care for individual patients i.e., requires PCP visit or interprofessional shared visit.
• Attempt two phone calls to discharged patients within 2 business days post-discharge if discharged home.
• Attempt two phone calls to discharged patients within 2 business days post-discharge from a temporary care facility if notified of their discharge.
• Coordinate care with clinic staff, communicating patient needs and barriers to care.
• Document all patient encounters in the appropriate electronic medical records systems.
• Manage Transitional Care Patient dashboard.
• Maintain scheduling and event calendars.
• Maintain accurate, detailed reports and records.
• Use computers for various applications, such as database management or word processing.
• Provide or arrange for training or instruction of auxiliary personnel as scheduled.
• Operate office equipment, such as fax machines, copiers, or phone systems.
• Engage in research activities related to nursing; if applicable.
• Complies with hospital policies and guidelines required for privileging and accessing facilities.
• Participate in clinic process improvement meetings and activities, if applicable.
• Knowledge of and compliance with HIPAA regarding protected health information.
• Adheres to all standards of Universal Precautions.
• Other duties as assigned.

• Communication, Oral - Ability to communicate effectively with others using the spoken word.
• Communication, Written - Ability to communicate in writing clearly and concisely.
• Confidentiality - Must maintain strictest confidentiality and comply with all HIPAA regulations and policies.
• Customer Oriented - Ability to take care of the customers’ needs while following company procedures.
• Decision Making - Ability to make critical decisions while following company procedures.
• Detail Oriented - Ability to pay attention to the minute details of a project or task.
• Ethical - Ability to demonstrate conducts conforming to a set of values and accepted standards.
• Friendly - Ability to exhibit a cheerful demeanor toward others.
• Initiative - Ability to make decisions or take actions to solve a problem or reach a goal.
• Judgment - The ability to formulate a sound decision using the available information.
• Organized - Possessing the trait of being organized or following a systematic method of performing a task.
• Patience - Ability to act calmly under stress and strain, and of not being hasty or impetuous.
• Problem Solving - Ability to find a solution for or to deal proactively with work-related problems.
• Responsible - Ability to be held accountable or answerable for one’s conduct.

Education: Associate degree (two-year college or technical school) required

Experience: 3-5 years’ experience in clinical or community health settings preferred

• Previous experience in caring for chronic disease patients required.
• Previous Care Coordination, Case Management or Home Health experience-preferred
• Bilingual in English and Spanish preferred
• Experience with navigation of local medical and social support systems -preferred
• Previous experience with health systems and data reports-preferred
• Knowledge of community health services
• Strong organizational and demonstrates the ability to maintain accurate notes and records.
• Strong interpersonal skills
• Ability to demonstrate strong essential leadership, communication, education and collaboration and counseling skills.
• Ability to communicate proficiently through technology (email, cell phone, etc.)
• Ability to identify and implement appropriate patient communication strategies and overcome accessibility barriers, as required
• Ability to demonstrate continual learning skills, effects changes in approach to care based on established, evidence-based practice.
• Ability to determine appropriate course of action in more complex situations
• Ability to work independently, exercise creativity, be attentive to detail, and maintain a positive attitude
• Ability to manage multiple and simultaneous responsibilities and to prioritize scheduling of work
• Ability to maintain confidentiality of all medical, financial, and legal information
• Ability to complete work assignments accurately and in a timely manner
• Ability to communicate effectively, both orally and in writing
• Ability to handle difficult situations involving patients, physicians, or others in a professional manner

The Company has reviewed this job description to ensure that essential functions and basic duties have been included. It is intended to provide guidelines for job expectations and the employee's ability to perform the position described. It is not intended to be construed as an exhaustive list of all functions, responsibilities, skills and abilities. Additional functions and requirements may be assigned by supervisors as deemed appropriate. This document does not represent a contract of employment, and the Company reserves the right to change this job description and/or assign tasks for the employee to perform, as the Company may deem appropriate.