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 services such as Home Health, Remote Patient Monitoring (RPM), Durable Medical Equipment, and pharmacy support as needed, and communicates with physicians. Nursing intake, assessment, planning, and care are performed in accordance with physician orders, the established plan of care, the patient’s diagnosis, applicable policies and procedures, and the Nurse Practice Act. The position provides clinical support and care coordination to patients and families as they move from active treatment toward managing their conditions independently. It collaborates with an interdisciplinary team, supports patient and caregiver communication by phone and/or video, and helps patients navigate procedures, admissions, follow-up care, and community resources. Coverage may be needed on weekdays and/or weekends.

Requirements

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

Responsibilities

Serves as a point of contact, clinical leader, and resource for staff and administration.
Provides patients and families with information needed to transition from active treatment to independently managing a condition.
Works as a member of an interdisciplinary team and encourages open communication.
Provides clinical supervision to the Care Transitions Tele Med-Assistant for patients and provides performance input to the appropriate manager.
Assists with orienting new staff or providing continuing education to existing staff as requested.
Helps identify patients who may be appropriate for Remote Patient Monitoring (RPM).
Establishes vital-sign parameters, obtains physician orders, develops plans of care, and documents findings.
Builds and maintains rapport with patients and caregivers through phone and/or video communication.
Continually assists patients and families in navigating the healthcare system, including procedures and admissions at TGH, follow-up, and community resources.
Assesses and evaluates patient data and needs and provides appropriate support, health education, direction, and intervention to patients and families.
Notifies physicians and other care agencies about changes in patient condition or status; sends reports, obtains new orders, and modifies the care plan as needed.
Identifies and recommends appropriate disciplines and community resources to support optimum patient care.
Maintains clinical skills within nursing practice norms and participates in group projects, training, and education as needed.
Informs the department manager of perceived issues related to the program, patient care, or community relations.
Demonstrates a professional attitude and sound judgment in interactions with physicians, healthcare providers, and community agencies.
Acquires and uses knowledge of community resources.