Mother​/Baby Registered Nurse Discharge Coordinator

Overview

Under general supervision, promotes throughput and care coordination with an understanding of the Maternal Newborn continuum of care. Provides both direct and indirect care to mothers and babies before and after discharge. Effectively reviews individual charts and rounds on all patients being discharged to assess for risk factors and determine best plan for post discharge phone calls. Determines eligibility for, completes and submits the Postpartum Infant and Maternal Referral (PIMR) form as required, providing the birthing parent with information and resources related to their specific need and risk.

Understands the Hospital Consumer Assessment of Healthcare Provers and Systems (HCAHPS) questions related to discharge, transitions of care, and communication about medications, incorporating this understanding into each interaction with the patient. Provides the Perinatal Program Manager with data based on patient feedback to inform improvement opportunities along with demonstration of compliance with the Maryland Maternal Health Act of 2024.

Associates Degree in Nursing, Bachelor’s Degree in Nursing preferred.

At least one (1) year experience in Mother Baby or Postpartum Nursing. Excellent assessment and effective communication skills required.

• Excellent clinical assessment skills and knowledge of community resources and referrals for outpatient care.
• Analytic skills in order to develop, measure and evaluate the planning and implementation of discharge phone calls, assessments and referrals.
• Substantial interpersonal skills required to effectively interact with patients and their families, both in person and via the phone.

• Must possess current Maryland State license as a Registered Nurse.
• Current Healthcare Provider BLS & NRP certification from an affiliated American Heart Association training site

Assessment

• Reviews patient charts both prior and after discharge to assess risk
• Interviews patients based on discharge needs and assesses clinical and educational risk
• Determines social determinants of health, respecting the diverse needs of each patient and family

Planning

• Collaborates with the patient to plan and schedule a discharge phone call within 24-48 hours of discharge
• Plans for addressing patient's individualized risk during post discharge phone call for each delivered patient

Implementation

• Implements chart reviews and rounds on all inpatients
• Prepares for and conducts discharge phone calls focused on the patient's individualized needs
• Implements interactions to assess mother and baby and share appropriate resources or referrals, both inpatient before discharge and outpatient within 24-48 hours. Documents assessments as well as any resources or referrals given

Evaluation

• Evaluates, creates and shares reports, metrics and time studies to ensure optimal workflow
• Evaluates improvement opportunities in nursing care based on patient feedback (nursing care, communication and education)

Orientation and Administrative

• Develops JIBS for the work of the Discharge Coordinator
• Works with Epic Analyst to determine and improve discharge milestones along with documentation of calls and referrals
• Orients interested staff to the role, creates coverage calendar and collaborates with MB manager to ensure coverage for 6 days/week

Other functions

• Assesses Mother Baby and Labor and Delivery census for eligible high risk inpatients requiring a PIMR, complete and submit form to the Maryland Department of Health
• Analyzes current discharge milestones for improvement in throughput
• Promotes throughput and care coordination for all delivered discharges based on expected maternal and infant milestones
• Demonstrates expertise in continuum of care pre- and post- delivery and serves as the point person for all OB practice managers as a liaison between outpatient and inpatient care

• Able to perform the physical requirements of the position, which may include activities related to patient care.
• Ability to stand and walk for prolonged periods
• Ability to sit for extended time to complete documentation and phone calls

• Exposu…