The Comprehensive CARE Center is a transitional clinic that bridges the gap between discharge and community. The Transitional Nurse Navigator (TNN) follow patients that have recently discharged with a high risk diagnosis (CHF, COPD, Sepsis). Under general direction, this role is accountable for the high-risk patient population. Ensures the continuity and coordination of patient care delivery by assessing patient needs; developing transitional care plans; identifies and leverages appropriate resources; and evaluates patient progress. Communicates patient care updates and other relevant information to all stakeholders in a timely and reliable manner. Under general direction, this role is accountable for the high-risk patient population. Ensures the continuity and coordination of patient care delivery by assessing patient needs; developing transitional care plans; identifies and leverages appropriate resources; and evaluates patient progress. Communicates patient care updates and other relevant information to all stakeholders in a timely and reliable manner.

• Identifies high risk patients through use of prospective risk stratification tool (e.g., high risk diagnosis, START, LACE, etc.)
• Completes comprehensive psycho-social assessments, consultation, treatment, and discharge recommendations, to include remote patient monitoring
• Provides complex care planning to high-risk patients in the community, via telephone calls, in-person meetings, telehealth, etc., according to established program protocols and policies
• Accepts responsibility for patients' Transitions of Care, coordinating provisions for discharge from facilities including follow-up appointments, home health, community services, transportation, etc., in order to maintain continuity of care
• Coordinates and facilitates communications between all patient settings, including acute care, ambulatory, short stay, skilled nursing, palliative care, and hospice
• Promotes patient self-management, educating patients on disease specific needs, medication, access to care, self-care support, to improve clinical outcomes and increase patient self-efficacy
• Identifies pts needs and makes appropriate referrals to programs/services (i.e. social worker, pharmacist, community agencies, etc.)
• Consults regularly with the inpatient team, PCP, supervisor, transitional team, and other team members to ensure that the transition plan remains relevant, appropriate, and achievable to changing patient status and/or goals
• Meets with patients while in the hospital to establish rapport and smooth transition to outpatient setting and follow-up
• Maintains effective relationships with patients and families, community-based agencies, and payers, facilitating interdisciplinary team meetings
• Collaborates and implements plans in accordance with established policies, prioritizing patient care goals and needs. Meeting with patients, patients' family and caregivers as needed to discuss transitional care and treatment plan
• Works proactively with patients, caregivers, and patients care team to identify an advanced care plan, including Advanced Directives and MOLST
• Implements plan of care for the patient by performing evidence-based interventions and treatments specific to the diagnosis or problem of the patient; administers treatment such as, lab draws, start IVs, injections, nebulizer treatments, wound care as directed by provider, and monitors patients according to their needs and acuity level. Performs symptom-based standing orders and plan of care
• Maintains accurate and complete records, initiates and oversees data entry into IT systems, documents all care rendered, pertinent patient information, all communications, and all care management decisions in appropriate database/electronic record
• Takes the lead on programs, identifying improvements and putting changes in place to better assist the high-risk population. Provides education to the team on information that will benefit patient outcomes
• Perform all other duties as assigned.
• Identifies high risk patients through use of prospective risk stratification tool (e.g., high risk diagnosis, START, LACE, etc.)
• Completes comprehensive psycho-social assessments, consultation, treatment, and discharge recommendations, to include remote patient monitoring
• Provides complex care planning to high-risk patients in the community, via telephone calls, in-person meetings, telehealth, etc., according to established program protocols and policies
• Accepts responsibility for patients' Transitions of Care, coordinating provisions for discharge from facilities including follow-up appointments, home health, community services, transportation, etc., in order to maintain continuity of care
• Coordinates and facilitates communications between all patient settings, including acute care, ambulatory, short stay, skilled nursing, palliative care, and hospice
• Promotes patient self-management, educating patients on disease specific needs, medication, access to care, self-care support, to improve clinical outcomes and increase patient self-efficacy
• Identifies pts needs and makes appropriate referrals to programs/services (i.e. social worker, pharmacist, community agencies, etc.)
• Consults regularly with the inpatient team, PCP, supervisor, transitional team, and other team members to ensure that the transition plan remains relevant, appropriate, and achievable to changing patient status and/or goals
• Meets with patients while in the hospital to establish rapport and smooth transition to outpatient setting and follow-up
• Maintains effective relationships with patients and families, community-based agencies, and payers, facilitating interdisciplinary team meetings
• Collaborates and implements plans in accordance with established policies, prioritizing patient care goals and needs. Meeting with patients, patients' family and caregivers as needed to discuss transitional care and treatment plan
• Works proactively with patients, caregivers, and patients care team to identify an advanced care plan, including Advanced Directives and MOLST
• Implements plan of care for the patient by performing evidence-based interventions and treatments specific to the diagnosis or problem of the patient; administers treatment such as, lab draws, start IVs, injections, nebulizer treatments, wound care as directed by provider, and monitors patients according to their needs and acuity level. Performs symptom-based standing orders and plan of care
• Maintains accurate and complete records, initiates and oversees data entry into IT systems, documents all care rendered, pertinent patient information, all communications, and all care management decisions in appropriate database/electronic record
• Takes the lead on programs, identifying improvements and putting changes in place to better assist the high-risk population. Provides education to the team on information that will benefit patient outcomes
• Perform all other duties as assigned.