Job Description

Oversees and provides primary care services to clients at an identified higher risk for rehospitalization by utilizing specific patient and family evidence-based interventions found in research validated care transition models. Leads a cohesive team in delivering at home clinical support and guidance to avoid adverse events. Collaborates continuously with other team members including medical staff to ensure care coordination and timely interventions based on assessed changes in status.

Job Responsibilities:

• Practices at the APRN level to ensure delivery of care coordination, including obtaining new medical orders that support clinical and social services according to the individualized patient plan of care
• Utilizes the Coleman Care Transitions model’s four (4) pillars to guide practice, prioritize care delivery, and facilitate self-care with evidence-based interventions.
• Provides medication reconciliation and medication adherence teaching to identified clients. Sets goals for self (family) management of medications
• Performs comprehensive assessment to facilitate understanding of the individual personal health record
• Ensures timely follow up with primary or specialty care provider
• Educates on red flag warnings and zone tools to avoid emergency department visits and/or rehospitalization
• Practices with an innovative virtual platform for managing patient alerts allowing for timely and efficient access to the clinical documentation and patient zone status throughout the agency
• Performs remote visits as needed with patients throughout the agency
• Serves as a resource to other professionals regarding transitional care needs including but not limited to wound care, disease management, and follow up care.
• Synthesizes higher level assessment data collected to implement evidence-based interventions to improve patient outcomes within the home health setting.
• Participates in quality improvement (QI) initiatives, policy development and education to implement best practices in rehospitalization reduction efforts
• Participates in root cause analysis (RCAs) of high-risk patients with variances to identify contributing or causative factors to improve quality outcomes and reduce rehospitalizations.
• Focuses on transitional care needs for patients within the 30-day length of stay (LOS) from an inpatient (overnight) care setting.
• Works in close collaboration with the telehealth nurse to ensure timely follow up with patients identified as having a change in status.
• Conducts in-home visits as clinically necessary
• Works in tandem with the provider who is directing the plan of care for the patient
• Demonstrates the ability to establish quick trust and therapeutic rapport with patients and families to provide effective patient education and influence patient and family self-management of disease processes.

Job Qualifications: Autonomous Practice APRN license in the State of Florida

• Three years’ experience in primary care, ambulatory care, or post-acute care setting
• Experience in and strong knowledge of medication management
• Strong organization and prioritization skills
• Able to practice with minimal oversight, self-directed
• Experience preferred with working in a virtual care environment