Transitions Coordinator RN - Cardiology

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Job Title: Transitions Coordinator RN
Department:  Cardiology
Location: Perelman Center for Advanced Medicine-3400 Civic Center Blvd
Hours: Part Time

Summary

The Transitions Coordinator works with the interdisciplinary health care team to facilitate patient understanding of their disease process and to promote care across the continuum based on evidence based clinical practice guidelines. The position requires expert communication skills and the ability to work collaboratively with a multi-disciplinary health team. The Transitions Coordinator maintains a strong component of patient advocacy and provides both formal and informal education for

professional, technical and ancillary personnel. The primary patient populations/diseases the Transitions Coordinator will be focused on are Heart Failure and AMI, but this role may expand into additional populations including Coronary Artery Disease, Arrhythmia, Peripheral/Vascular Disease and Cardiac Surgery.

Responsibilities

• Works daily to identify patients with HF and AMI in the hospital and coordinate their transitional care accordingly

• Educates and counsels patients and their families on disease and medication management and plan of care for both hospital and post hospitalization

• Participates in daily rounds and provides coordination among the interdisciplinary team ensuring adherence to AHA/ACC performance measures and ensuring compliance with all HF and AMI care elements

• Facilitates communication with nurses, attending/consulting physicians and other health care providers to discuss, confirm or make suggestions regarding patient management and evidence based standards

• Initiates or recommends referrals (consultations) to physicians and/or other health care providers (social services, case management, nutrition, physical therapy, cardiac rehabilitation, etc.) and provides information regarding community health programs to support risk management (smoking cessation classes, etc.)

• Lead the way in managing 90 day episodes of care for this population by interfacing with family, therapists, case managers, home care providers, etc. as needed, to identify specific discharge needs, facilitating optimal care transition and preventing re-admissions, Emergency Department visits and unscheduled office visits

• Evaluates identified patient records real time for compliance with evidence based standards of care by reviewing physician and nursing documentation and diagnostic studies

• Collaborates with Cardiology outpatient practices to ensure follow up appointments are made prior to discharge; assess patient’s unique needs and challenges at discharge to facilitate optimal care transition with the outpatient practice

• Performs post discharge follow up phone calls to patients discharged with a primary diagnosis of HF and AMI within 72 hrs of discharge

• Collaborates with multidisciplinary team to ensure all compliance elements and metrics are met for all patients prior to discharge and identifies opportunities for and provides both formal/informal education for health care providers

• Regular visits to key departments inclusive of medical/surgical (M/S) departments, critical care (CC) areas, the emergency department (ED) and support services for the purposes of providing feedback, discussing concerns, and identifying opportunities for education

• Track and trend data and metrics, identify patterns for readmissions

• Assists in leading hospital HF and AMI initiatives and participates in system wide HF and AMI initiatives

• Performs duties in accordance with Penn Medicine and entity values, policies, and procedures

• Other duties as assigned to support the unit, department, entity, and health system organization

Education and Experience

• Bachelors in Nursing (required) 
• 5+ years of cardiovascular nursing with critical care (required)
• Registered Nurse (required) 
• Basic Life Support Certification (required) 

We believe that the best care for our patients starts with the best care for our employees. Our employee benefits programs help our employees get healthy and stay healthy. We offer a comprehensive compensation and benefits program that includes one of the finest prepaid tuition assistance programs in the region. Penn Medicine employees are actively engaged and committed to our mission. Together we will continue to make medical advances that help people live longer, healthier lives.

Live Your Life's Work

We are an Equal Opportunity and Affirmative Action employer. Candidates are considered for employment without regard to race, ethnicity, color, sex, sexual orientation, gender identity, religion, national origin, ancestry, age, disability, marital status, familial status, genetic information, domestic or sexual violence victim status, citizenship status, military status, status as a protected veteran or any other status protected by applicable law.