Pool Care Transition Registered Nurse - TGH Ambulatory Care Transitions

Tampa General Hospital•Tampa, FL

About The Position

Under general supervision, the Pool Care Transition Registered Nurse provides patient education, support, and interventions to optimize care transitions and assist with compliance with the plan of care. The role coordinates Home Health, Remote Patient Monitoring (RPM), Durable Medical Equipment, pharmacy services as needed, and communication with physicians. Nursing intake, assessment, planning, and care are conducted in accordance with physician orders, the established plan of care, the patient’s diagnosis, applicable policies and procedures, and the Nurse Practice Act. Weekday and/or weekend coverage may be needed. The nurse serves as a clinical resource and point of contact for patients, families, staff, and administration, supporting patients as they transition from active treatment to independently managing their condition. The role works as part of an interdisciplinary team, supervises the Care Transitions Tele Med-Assistant clinically, helps orient and educate staff, and coordinates ongoing support through procedures and admissions at TGH, follow-up care, and community resources.

Requirements

Bachelor’s degree in Nursing.
Registered Nurse.
Minimum of three years of nursing experience, including experience in care coordination, ambulatory, post-acute, or transitional care settings.
Demonstrated clinical, interpersonal, and communication skills.

Responsibilities

Serve as a point of contact, clinical leader, and resource to staff and administration.
Provide patients and families with information and support for transitioning from active treatment to independent condition management.
Work as a member of an interdisciplinary team and encourage open communication.
Provide clinical supervision to the Care Transitions Tele Med-Assistant and provide performance input to the appropriate manager.
Assist with orientation of new staff and continuing education of existing staff as requested.
Help identify patients appropriate for Remote Patient Monitoring (RPM).
Establish vital sign parameters, obtain physician orders, develop a plan of care, and document findings.
Build and maintain rapport with patients and caregivers through phone and/or video communication.
Assist patients and families in navigating the healthcare system, including during TGH procedures and admissions, follow-up, and access to community resources.
Assess and evaluate patient data and needs, and provide appropriate support, health education, direction, and intervention.
Notify physicians and other care agencies about changes in patient condition or status, send reports, obtain new orders, and modify the care plan as needed.
Identify and recommend appropriate care disciplines and community resources to optimize patient care.
Maintain clinical skills within nursing practice norms and participate in group projects, training, and education as needed.
Inform the department manager of perceived issues related to the program, patient care, or community relations.
Demonstrate professionalism, sound judgment, and continuity in interactions with physicians, healthcare providers, and community agencies.
Acquire and use knowledge of community resources.
Coordinate Home Health, RPM, Durable Medical Equipment, pharmacy services as needed, and communication with physicians.