RN-Transition of Care Navigator

Job Summary:

The Transitions of Care (TOC) RN Navigator plays an integral role in identifying post-acute needs of patients with chronic disease illness or end of life needs. This role is crucial to preventing readmissions and facilitating appropriate referrals for patients who are at high risk for readmission and serves as an extension of the quality team with a higher level of responsibility for directly impacting patient outcomes.

The TOC RN navigator’s primary role is to provide patient advocacy, coordination of care, and ongoing education and resource management to patients and families. This may include services available within the Forrest Health system as well as within the broader community with regards to chronic disease management. The TOC RN Navigator will review patients daily, specific to triggers that identify a need for post-acute care services.

The TOC RN navigator is to be an extension of the palliative care and rural health providers within the organization. Once patients are identified as potential readmissions with specific high-risk diseases, as identified by specified triggers within the medical record, the TOC RN navigator’s primary role is to create a signal to post-acute care teams and to case management for referral.

This RN reviews this list daily and follows specific patient cohorts by disease stratification. The goal is for day one review and capture of patients who are palliative care, hospice, or home health appropriate to improve the quality of life for every cohort and disease specific patient within the system. Serving our rural health community, the TOC RN Navigator collaborates with our admitting and discharging providers, case managers, social workers, and patient families to keep cohort patients well at home and to foster treatment plans that keep the patient closest to home, fully at the discretion and choice of the patient.

This RN is responsible for tracking patients and providing data analytics regarding the success of the program. Those data analytics will be driven by the executive director of the post-acute services team. This RN will review readmission data, palliative care and hospice data, and all other services which may indicate improved care and quality of life for these patient cohorts.

This position reports to the Executive Director.

Key Responsibilities

Transitions of Care Coordination

• Actively demonstrates the organization's mission and core values, and conducts oneself at all times in a manner consistent with these values.
• Knows and adheres to all laws and regulations pertaining to patient health, safety and medical information.
• Manage and prioritize a daily Transitions of Care Operational List, identifying patients requiring assistance education and support regarding post-acute care services.
• Facilitate conversations regarding disease process and to create a seamless transition of decision making from the family to the case management and social work team, as well as medical providers.
• Coordinate patient contacts (virtual or in-person) with palliative, hospice, and post-acute care service teams, to expedite decision-making and placement.
• Ensure timely communication and documentation related to discharge planning and post-acute transitions.

Interdisciplinary Collaboration

• Serves as a clinical resource and advisor to hospitalist physicians, case managers, and social workers regarding post-acute care options and eligibility criteria and presents post discharge options to the appropriate provider group for review.
• Participate in interdisciplinary rounds and care planning discussions to proactively address education and resource needs for the patient.
• Collaborate with internal departments and external partners to improve patient flow and reduce avoidable length of stay.

Patient and Family Support

• Educate patients and families on disease process, palliative care programs, post-acute care options, levels of care, and available community resources.
• Support shared decision-making while respecting patient preferences, clinical needs, and payer requirements.
• Serve as a patient advocate in relation to placement, transportation, or access to services.

Quality,…