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- Identifies the needs of patients and families and coordinates internal and external community resources within the first month of hospital discharge to reduce post-hospitalization illness/disease.
- Works closely with case manager to identify high risk patients. Creates a care plan to ensure patient has appropriate resources necessary to lower readmission rates.
- Maintains caseload of patients following discharge to ensure patients receive appropriate home visits, are being seen by primary physicians and taking their medications as needed.
- Facilitates communications between and negotiates with patient/family, physicians, nurses, dietary, rehab, homecare, social services and other disciplines that need to collaborate to provide care for the patient.
- Identifies, evaluates and acts to resolve any potential barriers to delivery of care and a timely and appropriate discharge. May coordinate and document discharge plans of care.
- Works closely with the medical staff, hospital departments and ancillary services in expediting care delivery and appropriate documentation to avoid delays in timely service provision. Validates care that is provided.
- Collaborates as a partner with jointly assigned social worker to ensure safe and appropriate discharge planning.
- Collaborates with physicians daily regarding patient care course. Makes suggestions in expediting care and modification to a tentative on a timely basis.
- May works as a member of the Outcome Facilitation Team (OFT) in a collaborative and proactive manner to promote best practice. Works with the patient care manager and clinical nurse specialist of the unit to proactively achieve the objectives outlines in the multidisciplinary Outcome Facilitation Team meetings.
- Registered Nurse license issued by the state of Illinois or Wisconsin.
- Bachelor's Degree in Nursing preferred.
- Typically requires 2 years of experience in nursing in an acute care or community setting with an emphasis in palliative care or senior services.
- Excellent written and verbal communication skills.
- Strong organizational, analytical and problem solving skills.
- Ability to educate clinical staff and the community.
- Ability to work well with physicians and other healthcare professionals.
- Ability to work in a team based multidisciplinary environment.
- May need to operate a motorized vehicle to facilitate home visits as appropriate.
- Must be able to sit, stand and walk without restriction.
- Must have the ability to move about in confined spaces, including bending, twisting, kneeling, squatting and occasionally reaching one or both arms overhead.
- Must be able to conentrate on detailed information, tasks, and functions for prolonged periods of time.
- Must be able to speak clearly and hear in order to communicate in person or via telephone.
Care Transitions Nurse, Full time - Rolling Meadows, United States - Advocate Aurora Health
Description
Department:39732 Accountable Care Admin - Care Transition and Support Programs
Status:
Full time
Benefits Eligible:
Yes
Hours Per Week:
40
Schedule Details/Additional Information:
POSITION HOURS & REQUIREMENTS:
Monday-Friday; 8a-4:30p
including some evenings and weekend coverage
MUST have High Speed internet
Must be a resident of Illinois or Wisconsin
Major Responsibilities:
Advocate Aurora Health is one of the 10th largest not-for-profit, integrated health systems in the U.S. with nearly 3 million patients served at more than 500 sites of care in Illinois and Wisconsin, including 28 hospitals. We're redefining the standard for care with world-class doctors and caregivers, innovative solutions, outstanding outcomes, and leading-edge research and clinical trials. Combined, Advocate and Aurora are recognized for clinical excellence in a variety of specialties. Advocate Aurora Health is one of the 10th largest not-for-profit, integrated health systems in the U.S. with nearly 3 million patients served at more than 500 sites of care in Illinois and Wisconsin, including 28 hospitals. We're redefining the standard for care with world-class doctors and caregivers, innovative solutions, outstanding outcomes, and leading-edge research and clinical trials. Combined, Advocate and Aurora are recognized for clinical excellence in a variety of specialties.