Transitional Care Management (TCM) provides comprehensive, consultative and management services that enhance patient satisfaction, reduce costs, and improve outcomes. The Transitional Care nurse will support the organizational transitional care program by providing and interactive contact via telephone call with the patient and/or caregiver within two business days following the patient's discharge to the community setting. Using the nursing process, the TCM nurse will assess the patient's transition to home, understanding of discharge instructions, medication compliance and will direct patients to the appropriate level of care within the organizational health care system. The TCM Nurse is accountable for quality assessment, efficient managed care, and client satisfaction in collaboration with the health care team. The TCM nurse will utilize multiple IT platforms for patient identification and documentation of transitional care interventions. The delivery of professional nursing care at Stormont Vail Health is guided by Jean Watson's Theory of Human Caring and the theory of Shared governance, both of which are congruent with the mission, vision, and values of the organization.
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Job Type
Full-time
Career Level
Mid Level