Nurse Navigator - Cystic Fibrosis Clinic

Location Detail: 79 Retreat Ave HH Brownstone (10065)

Shift Detail: Week Days

Work Location Type: In Person

Work where every moment matters.

Every day, more than 40,000 Hartford Health Care employees come to work with one thing in common:
Pride in what we do, knowing every moment matters here. We invite you to become part of Connecticut’s most comprehensive healthcare network.

Hartford Hospital is one of the largest and most respected teaching hospitals in New England. We are a Level 1 Trauma Center that provides cutting edge treatment to its patients. This is made possible by being home to the largest robotic surgery center in the Northeast and the Center for Education, Simulation and Innovation (CESI), one of the most-advanced medical simulation training centers in the world.

When hospitals cannot provide the advanced care, expertise and new treatment options their patients require, they turn to us.

Job Summary:
Functioning within the context of the framework for professional nursing practice, the Cystic Fibrosis Clinic Nurse Navigator is a registered nurse experienced in patient throughput, preventing transitional care gaps, and resolving issues to enhance the quality and continuity of a patient’s or populations health care leading to improved health outcomes and equitable care. This role supports the HHC mission to improve the health and healing of the people and communities we serve.

Under provider direction, the Cystic Fibrosis Clinic Nurse Navigator provides skilled nursing care to patients in a variety of clinical settings. Scope of responsibility is characterized by use of nursing process to assess, plan, intervene and evaluate human responses to actual or potential health problems utilizing appropriate practices, standards, protocols and guidelines. This position reports to a Nurse Manager Manager.

Job Responsibilities:

• Functions as a member of an interprofessional care team in an expanded nurse role to help patients transition from the acute care setting (HH ED or inpatient). The goals include reducing all-cause readmissions, and inappropriate ED utilization, improving care coordination for patients during the transitional care period, and ultimately improving care quality and access for vulnerable populations. This role will be responsible for educating the HH community at large and advocating for resources to enhance patient healthcare engagement and expand the collaboration and communication between (inpatient/ambulatory/outpatient/attending/transitional care/specialty care/primary care) providers and care teams for high risk/complex patients.

• Partners with the inpatient (i.e. acute care, IOL, STR) or ED physician and care team to proactively identify potential transitional care gaps for this patient population, and establish a safe transition plan. Key strategies include ensuring a patient/caregiver agreed upon CF Clinic and urgent specialists scheduled appointment(s) with transportation, verifying patient has necessary DME, finalizing an achievable community medication plan, completing diagnostic workup, educating the patient on disease and symptom management, and incorporating a patient-centered home care plan.

• Performs post-hospitalization/ED transitional care strategies within 24-48h after discharge, including post-discharge phone calls, patient education, symptom management, and medication reconciliation, and collaborates with CF clinic physician and (clinic and community) care team to minimize identified gaps in care.

• Throughout the post-inpatient/ED transitional care period, facilitates the completion of the diagnostic workup, follows up on unresulted diagnostics, collaborates with homecare, pharmacy, and DME to ensure the patient has necessary supplies/medications/resources, obtains necessary authorizations, and schedules additional consultant appointments.

• Collaborates with clinic physicians to resolve issues and to advance the treatment plan until the patient has an established primary care provider.

• In collaboration with the CF Clinic physician, assists the patient in identifying a primary care practice for continued care and facilitates the transfer of care to…