Associates Degree in Nursing (ADN) minimum
The RN Care Transition Coordinator will be responsible for community and staff education of the care transition program chosen for the Innovation Grant implementation, education and training of all hired RN care transition nurses and support for continued skill development. The RN Care Transition Coordinator ensures safe and effective patient transfers across the continuum of care by serving as a bridge between the patient and/or primary caregiver and professional staff and educating/coordinating the RN care transition staff. The RN Care Transition Coordinator serves as patient advocate, patient empowerment facilitator, and provides information and guidance for effective care transitions, improved self-management skills, and enhanced patient-professional communication.
1. Educates, trains and orients all RN care transition nurses hired for the care transition program and assures program guidelines are followed in all training and continued skill development activities.
2. Coordinates the activities of the care transition nurses and provides support, assistance and ongoing education/skill development. Assists with community education.
3. Collaborates with interdisciplinary team by assessing patient’s psychological, social, emotional, physical, and financial needs related to health self-management and care transitions; assists in guiding activities, nursing treatment modalities, and interventions of other practitioners based on those assessed needs; monitoring patient’s response to treatment and working with patient’s team to analyze and deal with unanticipated developments.
4. Conducts marketing activities with key stakeholders, promotes and inspires referrals to the program, and educates providers on the value of the program in meeting the facility goal of decreasing unnecessary readmissions.
5. Builds trust and rapport with patient and/or primary caregiver, while assisting patient and/or primary caregiver to set goals for treatment and general health at admission to the program and to develop a follow-up plan to work toward achieving their goals; p rovides in-patient and post-discharge visits and phone follow up to patients who meet program criteria.
6. Provides information, education, and support to patient and/or primary caregiver regarding disease(s) self-management.
7. Assists patient and/or primary caregiver to understand, create, and utilize a personal health record, including assistance in formulating key questions and/or concerns to ask health care providers; thereby empowering patient and/or primary caregiver to make contact with health care providers when indicated and to begin taking a more active role in managing their health care.
SKILLS, KNOWLEDGE, AND ABILITIES
- Demonstrates effective leadership and professional skills according to Standards of Care.
- Ability to educate and train nurses to emulate care transitions program, in order to have expected outcomes.
- Ability to assess a patient’s condition, formulate plan of care, select appropriate interventions, evaluate patient’s response to plan of care and to explain to patient/family about this process.
- Ability to assess, evaluate, explain, teach, problem solve using critical thinking; and perform calculations.
- Demonstrates excellent professional/clinical skills and utilization of the Nursing process of direct and indirect patient care which includes assessment, planning, implementation and evaluation of nursing care to meet patient needs and improve patient outcomes.
- Ability to work independently, while collaborating with other team members.
- Ability to make independent decisions in accordance with established policies and procedures.
- Knowledge and appreciation of cultural diversity and low literacy issues, and how those factors can affect coaching and health care provision.
- Knowledge of hospital structure, nursing policy and procedures, and chronic disease management.
- Licensed at the RN level through the Wyoming State Board of Nursing
- Minimum 3 years of experience in acute care nursing, home health experience preferred
- Current CPR ( BLS )
- Valid driver’s license
- Ability to drive to and from a variety of settings in varying weather conditions
- BSN from an accredited school of nursing
Cheyenne Regional Medical Center - 22 months ago
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