Job Description

of Essential Functions

• Supports, guides, and coordinates patients and their caregivers toward optimal care outcomes
• Develops relationships with patients and their caregivers, health care providers, and other key stakeholders to assist in maintaining an appropriate plan of transition from acute care to the most appropriate post-acute service.
• Conducts an assessment of the patients’ status upon program entry and directs referrals for screenings.
• Functions as a program liaison to physicians and other healthcare professionals.
• Assists with development of other patient education activities that focus on health promotion and wellness based on community needs.
• Responsible for providing direct self-management education.
• Assist as needed in collection of statistical data.

Educational Requirements

• Graduate of an accredited RN program.
• Must be able to communicate effectively in English, both verbally and in writing.

Licenses and Certifications

• CPR Certification
• Registered with the Board of Nursing for the State of Texas.

Knowledge/Skills/Abilities

• Demonstrates competency in the care of patients.
• Uses common sense and special nursing skills to care for the sick or handicapped.
• Understands information from supervisors, charts, reference books, manuals, and labels
• Must have good computer skills.
• Communicates with people when they are sick, handicapped or nervous and works quickly and efficiently in an emergency.
• Ability to change from one duty to another frequently, follow reasonable instructions, and record information accurately.
• Sets priorities, makes decisions based on available data and supervises others.
• Remains current in continuing education in both the nursing profession and in the field of specialty.

Physical Requirements

• Primarily works the day shift tour of duty; additional hours may be asked to work other hours as needed, including weekends
• May be expected to lift over twenty five (25) pounds
• Ability to distinguish between numbers and symbols
• Hand-eye coordination and manual dexterity with substantial movement of wrist and/or fingers
• Walking and climbing to accomplish tasks.
• Corrected vision and hearing to normal or near normal range.
• Extended periods of sitting and/or walking depending on specific duties.

Duties and Responsibilities

• Collaborate with appropriate stakeholders to promote appropriate, timely, and smooth transitions to the appropriate level of care. Provide rapid response to referrals to include contact with the patient and caregiver, referral sources, and other members of the care team.
• Collaborate with the medical providers and others to improve quality of life and clinical outcomes for patients and their families. Provide education to the patient and caregivers about what to expect both in the immediate and subsequent transitions.
• Works collaboratively with the inpatient and outpatient health care team to coordinate seamless care for clients customized to their individual situations and needs.
• Establish collaborative partnerships with the patients and families to assist them in examining patterns of their health care needs and decisions, lifestyle choices, and utilization of resources that affect their health.
• Assesses the patient’s readiness to learn, level of understanding, and individual goals. Plan an individualized education approach to achieve goals. Implement teaching protocols for helping patient/caregiver learn. Evaluate patient’s understanding and goal achievement. Document education process in the medical record.
• Collaborate with health care provider and agencies using a multidisciplinary approach to help the client and the family set realistic and achievable goals to achieve the desired outcomes.
• Formulates a goal directed plan of care that addresses patient’s educational needs in conjunction with the physician. Integrates the plan of care with potential needs at home. Formulates discharge plan of care.
• Educates and coaches patients and families to help them develop self-care skills and independence appropriate to their age and developmental level which may include their primary caretakers.
• Ensure follow up of identified barriers/issues to resolve issues that may negatively impact the patient’s ability to self-manage at home.
• Utilize professional and community knowledge and influence to obtain resources in the most cost effective manner to best meet the patient’s developmental, physical, psychosocial, environmental, spiritual, cultural and financial needs.
• Participate in performance improvement activities as outlined by appropriate process improvement teams. Provide feedback to the referring team on the status of the plan for the purpose of improvement and development of standards of care.
• Provide a warm hand off to the post-acute service, communicating the information critical to a successful outcome. This information includes but is not limited to: social situation, barriers to success, caregiver specific facts.
• Facilitate patient/caregiver engagement in the post-acute discharge plan.
• Judges the effectiveness of care on each patient visit. Evaluates patient’s response to care provided and patient/caregiver self-care responsibilities in relation to education. Formulates and documents results of follow-up evaluation/visits.
• Participate in the development of disease management strategies, measurement of patient outcomes related to hospital utilization, community outreach presentation, education, and groups related to disease management issues.
• Assist in formulating patient teaching protocols for patients served.
• Document of assessment and progress notes/flow sheets are thorough and timely
• Performs all other tasks/responsibilities as necessary.