Under general direction of the PBMT Medical Director and in collaboration with the multidisciplinary transplant team, the nurse coordinator provides expert nursing care for transplant, cell and gene therapy patients, including candidates (pre-transplant), recipients (post-transplant) and/or donors with a variety of complex treatment options. The nursing coordinator serves as a contact point for transplant patients, family members, referring physicians, staff as well as contact point for the coordination and facilitation of the care of the patient in specialty areas. The nurse coordinator provides leadership for collaborative and multidisciplinary patient care with emphasis on education and continuity of patient care for the entire period of care including inpatient, outpatient, or both. The transplant nurse coordinator is responsible for monitoring and coordinating the care of transplant patients to ensure they reach their maximum health potential before and/or after transplant.
Specific daily responsibilities include triaging patient calls and test results, coordinating organ evaluation studies and specialty referrals, confirming orders, providing ongoing transplant patient education, spearheading the coordination of care for the transplant patient across disciplines, resourcing and assisting nursing with cellular therapy infusions, coordinating discharge care, and clinic work as needed.
This position will support the transplant team by communicating with patients on behalf of providers. Respond to changes in patient condition as exhibited in signs, symptoms and lab values in collaboration with the provider. The nurse will make changes to medication and treatment plans as delegated by the provider. The nurse coordinator will educate patient on any changes and document in the EHR. Lastly, they will prep and review charts for providers for patient pre and post-transplant ambulatory visits.
%
of time
Essential Function (Yes/No)
Key Responsibilities
(To be completed by Supervisor)
90%
Yes
• Coordinate the efforts of the multidisciplinary transplant team, consulting services and nursing staff on behalf of the transplant candidate and donor.
• Provide transplant-specific nursing care for pre- and/or post- transplant, cell and gene therapy patients who have a variety of complex medical issues.
• Provides ongoing patient education for the transplant patient and family.
• Serves as multidisciplinary contact point for all patient requests, studies, and other needs.
• On behalf of the patient, serves as primary point of contact for phone calls, requests, inquiries by patient, family members, and outside care providers.
• Facilitates labs, diagnostic studies, such as ultrasound, x-rays, interventional radiology procedures, nuclear medicine scans, echocardiograms, pulmonary function tests, central line placement, and other procedures as needed. Obtain the results of studies done at other centers. Notifies provider of results as appropriate.
• Initiates MD consultations and referrals for the transplant patient as requested by provider.
• Assesses subjective and objective data and escalates appropriately.
• Reviews patient charts and medication profiles to confirm compliance to treatment regimen and protocols as established by transplant providers. Provides ongoing patient education of treatment plan.
• Communicate lab results and medication changes to patients by telephone under the direction of the transplant provider.
• Documents clearly and thoroughly; documentation includes but is not limited to patient records, requisitions, referrals, and billing. Utilizes electronic medical record for documentation.
• Using good documentation practice, prepares critical documents for attending signatures, ensure all critical documentation is present in the medical record at critical time points.
• Exhibit independence, self-direction and accountability to the patient, family, and transplant team
• CCS care coordination
• Participate in the multidisciplinary evaluation of the candidate and donor.
• Present the candidate and donor at transplant administrative meetings.
• Facilitate the multidisciplinary work-up of the candidate and donor, and compile data into the pre-transplant evaluation.
• Reviews medication profiles and together with the primary attending, flags potential medications that could impact the conditioning regimen plan.
• Coordinate appointments and consent conferences from referral to admission to post-discharge.
• Coordination of apheresis and cell infusions with the apheresis team and pediatric cell therapy laboratory.
• Coordinate with manufacturers and cell/gene therapy patients cell enrollment of patient through cell collection, manufacturing, receiving and cell/gene therapy product, infusion of therapy.
• Coordination of discharge:
patient education, central line care teaching, post discharge BMT isolation
Scheduling follow up appointments and obtaining a general understanding of insurance and authorization.
Work with home health and supply companies to provide patient supply and home care needs. This will include coordination of in-person teaching by home health/supply hospital liaisons for any home health supplied therapies prior to discharge (i.e. infusion pumps).
• Support the bedside nurse and cellular therapy lab with inpatient cellular therapy infusions and procedures (such as CTLs, NK cells, granulocytes, ECP, transport to another hospital, etc) and resource bedside RNs for BMT specific issues and questions during business hours
• Follows immunosuppression drug levels and make dose changes as requested by transplant providers. Notifies patients of dose changes and ensures patient understanding of medication changes.
• Coordinates clinic visits with infusion center needs, assists in scheduling referrals.
• Liaison with Pediatric Infusion Center and Specialties Clinic to optimize patient flow.
• Review prescription refill requests, present to APP for approval, call to pharmacy when necessary. Communicates accurately and professionally with pharmacies.
• Assist in completion of medication prior authorization forms.
• Assist in completion of disability, return to work and other patient forms.
• Assist in post-transplant coordination of home health needs.
• Coordination of donor lymphocyte infusions and cellular infusions in clinic.
• Coordination of multidisciplinary clinics.
• Identifies the needs and responses of patients to medical regimen and treatment through observation of symptoms, emotional state, and cultural and socioeconomic background
• Recognizes and reports specific physical and emotional conditions/needs/concerns of the patient to appropriate members of the health care team
• Works cooperatively and participates with the health care team to meet the patient's needs
Identifies and utilizes appropriate resources (e.g. social work, child life, etc.) for patients with social, parenting, personal or other concerns
3%
Yes
Support in preparation for regulatory surveys by FACT, and CMS as requested.
Performs regulatory chart audits in compliance with Ambulatory Nursing Administration guidelines.
Complies with all Ambulatory Services and Medical Center policies and procedures for infection control, safety, administrative and clinical practices. Complies with activities mandated by TJC/Title 22/NCQA
Completion of annual review, trainings, competency testing
S/he will document and maintain a record of prescription refills, medication authorizations and all patient interactions via APEX.
1%
Yes
Provides individualized nursing care that responds to the growth and developmental needs of patients and demonstrates an understanding of the range of treatment required by the patient
Demonstrates ability to provide appropriate care based on the needs of a specific individual, including that individual's age. Check age-specific group(s):
Neonatal (Birth - 1 year)
Pediatric (1 - 12 years)
Adolescent (13 - 18 years)
Young Adult (18 – 20 years)
Prepares for and instructs patients about specific diagnostic and therapeutic procedures and treatments as appropriate.
Responds appropriately in emergencies.
3%
Yes
Participates in Performance Improvement (Pl) activities
Makes recommendations regarding Pl topics or problems; and assists in data collection
Reports and follows up on issues that affect environment and safety
Maximizes resources by seeking assistance from appropriate support, effectively using supplies, making suggestions for improved approaches, assists in cost- effective practices.
Updates patient education materials biannually.
3%
Yes
Attends classes, conferences, workshops and staff meetings applicable to practice needs. Shares information from programs attended.
Complies with work related policies, including license renewal, annual PPD, CPR certification, use of benefit time, and dress code including identification policy
Contributes to the orientation and learning experiences of other members of the health care team
Participate in trainings concerning cell and gene therapy products.
Teaches coordinator portion of the intro to BMT course, updates nursing on BMT practice changes in staff meetings.
Complies with departmental scheduling guidelines; i.e., starts work at times scheduled, completes work in a timely manner
Required Qualifications:
Preferred Qualifications:
Required License/Certifications:
