General Summary The Center for Medicare and Medicaid Innovation Complex Care Nurse Clinician emphasizes population-based outcomes improvements in health status, efficiency, and care delivery through care coordination, health promotion and disease prevention as they assist patients and families to navigate uneventfully, efficiently, and as effectively as possible through the course of their illness. The Clinician identifies patients who are not navigating well through the health care system, assesses key needs, and addresses local and systemic issues interfering with care, helping high need patient populations achieve better outcomes. The Clinician must be a flexible problem solver on multiple levels, from patient-level, to disease population, to care system. The Clinician achieves this ends by activating the health care system on behalf of these high need patients, including delegates, supervises and provides care coordination; plans for education; and provides for patient safety and quality of care.
Principal Duties and Responsibilities: · Implements interventions designed to improve health, care, and cost in the PFK population. · Works with Program Coordinator and Medical Director of Complex Care to identify patient subpopulations requiring assistance in care or in accessing services, and develops programs to assist families to obtain those needed services. · Outreach to primary care physicians, specialty physicians, and other service providers to identify patients in need of care coordination. · Works closely with families to guide them through the health care system to optimize the care and services they obtain to improve child health through better, more efficient care.
Reassess patients and revise plan of care as appropriate 5. Anticipate patient needs regarding organizing services, additional needs, etc. 6. Plan, provide, delegate, and evaluate patient/family education as appropriate 7.
- Expertly uses and serves as a resource for the nursing process, Standards of Care, clinical pathways, and clinic specific competencies, to: 1. Complete the appropriate health status assessment 2. Document a plan of care in the appropriate system 3. Evaluate patient care and patient’s response/progress 4.
Collaborate effectively with all health care disciplines to facilitate optimal patient and family health and full potential · Demonstrates awareness of and support for the principle of Family Centered Care. · Communicates patient care needs/expectations/priorities to primary care physicians, specialty physicians, and other service providers. · Effectively relates and interacts with patient, families, and health care team and serves as a role model for others. · Effectively manages patient care through one or more of the following: a.
Delegating and coordinating care for patients b. Care conferences c. Clinical rounds d. Other coordination activities · Collaborate with internal and community resources to promote a healthy lifestyle and prevent escalation of health conditions; · Maintains professional standards and serves as a role model by setting professional goals and participating in activities to meet goals.
2. Must be able to work for extended periods on the phone. 3. Must be able to travel to other settings to meet with and coordinate care for patients.
- Participates in clinic, hospital meetings, and shared governance/unit council. · Coordinates research, quality improvement activities, and special projects. · Participates in evidence based practice through application of policy, review of literature, and/or participation in nursing research. · Accepts and supports change in a positive manner.
- Plans, implements and evaluates program changes. · Practices professional nursing in accordance with ANA Code of Ethics for Nursing. Minimum Requirements · Graduate of an approved school of nursing, BSN highly preferred. Will consider ADN with requirement to successfully complete BSN within 5 years of start date.
- Licensed as a Registered Nurse in the State of Ohio. · Three years pediatric clinical experience or equivalent combination of education/experience preferred. Minimum Physical Requirements 1. Must be able to see, hear, stand, walk, speak, read and perform manual tasks with or without accommodation, and care for oneself with little or no difficulty.
Nationwide Children's Hospital - 23 months ago
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