Nurse Transition Coach NTC

Overview

St. Francis Hospital, The Heart Center is New York State's only specialty designated cardiac center. A member of Catholic Health Services of Long Island, St. Francis is consistently recognized by U.S. News & World Report as a national leader for Cardiology & Heart Surgery, as well as for Gastroenterology & GI Surgery. Additionally, U.S. News rates St. Francis as high performing in Geriatrics, Neurology & Neurosurgery, Orthopedics, and Pulmonology.

Nursing care ncis is also nationally recognized, with multiple Magnet designations, as well as the AMSN PRISM Awards and Beacon Awards. St. Francis has regularly out-scored other hospitals on Long Island.

St. Francis Hospital is dedicated to providing a supportive environment, committed to the highest standards of patient care, where health care professionals can develop their expertise and strengthen their credentials.

Job Details

* Identifies inpatients at risk for readmission using electronic health record (EHR) and other patient identification software platforms.

* Assists patients in understanding their diagnosis, treatment options and resources in a manner that is culturally and linguistically appropriate and respects patients' care preferences.,

* Identifies co-learners, as appropriate, and provides educational materials and referrals for health maintenance. Communicates the importance of compliance with diet, medication regimen. Educates patients and co-learners on signs and symptoms of exacerbation or relapse of the disease condition.

* Serve as an essential link between the patient and other care providers, including primary care, disease-specific care, home care and skilled nursing facilities as appropriate.

* Participates in the ongoing development of patient education programs and tools for patients, transitions of care pharmacists, nursing and APP staff.

* Collaborates with the direct care team to assess patients for socioeconomic and psychosocial barriers to care, goals of care, and post-discharge needs and preferences.

* Navigates patients across the care continuum, including inpatient admissions, and collaborates with the treatment team to prepare a safe and effective discharge plan.

* Collaborate with Care Management Department, Medicine, Nursing, Clinical Progression and the Readmission Reduction Task Force to track outcomes and support strategic planning.

* Maintains working knowledge of requirements, inclusion and exclusion criteria and ensures interventions are updated to aligned with the goals of the CMS Hospital Readmission Reduction Program.

* Monitors performance toward the St Francis Hospital and Catholic Health Quality Plans and reports trends in unplanned returns to the hospital. Assists in the collection of data for reporting to the Hospital and System governing bodies.

* Collaborates with community providers to ensure comprehensive care and effective communication regarding patient progress and needs.

Educational Requirements

Active NY State registered licensed RN, BSN required

This range serves as a good faith estimate and actual pay will encompass a number of factors, including a candidate's qualifications, skills, competencies and experience. The salary range or rate listed does not include any bonuses/incentive, differential pay or other forms of compensation that may be applicable to this job and it does not include the value of benefits.

At Catholic Health, we believe in a people-first approach. In addition to the estimated base pay provided, Catholic Health offers generous benefits packages, generous tuition assistance, a defined benefit pension plan, and a culture that supports professional and educational growth