RN Care Facilitator, Ed BWH

Mass General Brigham•Boston, MA

8d•Onsite

About The Position

The Emergency Department Care Facilitator (EDCF) proactively coordinates patient care in a fast-paced emergency department. Using clinical assessment skills, the facilitator identifies patient needs, coordinates care, manages utilization, supports safe transitions of care, and helps maintain patient flow and throughput. The EDCF partners with ED physicians, nurses, the interdisciplinary team, and community resources to support timely and appropriate care decisions. The facilitator coordinates implementation of care plans and supports transitions from the ED to appropriate care settings. This includes assessing care needs with the interdisciplinary team, identifying discharge support needs, considering alternative care sites, reviewing medical history and treatment plans with ED providers, participating in patient rounds, and communicating follow-up plans for high-risk patients. The role works with patients, families, caregivers, community providers, hospitals, facilities, home health agencies, ED social workers, and staff nurses to arrange post-ED care and promote continuity. The EDCF also contributes to admission decisions and utilization improvement by assessing the appropriateness of admission, identifying unmet insurance needs, recommending alternative care sites, and applying knowledge of emergency medicine, levels of care, utilization management, and community resources. The role participates in evaluating practice patterns and systems and supports improvements in care quality, cost, and satisfaction. The position is onsite at Brigham and Women's Hospital and has a 36-hour variable rotating schedule.

Requirements

Graduate of an approved school of nursing.
Current Massachusetts nursing registration.
A Bachelor of Science degree in Nursing is required for newly licensed nurses.
Five years of previous acute care experience.
Five years of experience in an acute setting with discharge planning and knowledge of community resources.
Knowledge and skills to differentiate levels of care.
Ability to demonstrate the knowledge and skills necessary to provide care appropriate to the ages of patients served on the assigned unit.
Strong clinical assessment skills.
Excellent interpersonal skills, including the ability to work collaboratively and cooperatively within a team.
Strong organizational skills and ability to set priorities.
Ability to compile data from concurrent and retrospective medical record review to determine clinical appropriateness and level of care.

Nice To Haves

Emergency nursing experience is strongly preferred.
Two or more years of hospital utilization review experience preferred.
Bilingual English/Spanish skills preferred.

Responsibilities

Coordinate and ensure implementation of the plan of care using case management principles.
Facilitate transitions of care and identify opportunities to improve utilization of care delivery resources.
Collaborate with the interdisciplinary team upon ED presentation to assess care needs and determine discharge support or transition needs.
Present alternative care delivery sites to ED providers and, when appropriate, patients and families.
Review patients’ medical histories and current treatment plans with ED providers to support care coordination and resource utilization.
Participate in ED patient rounds to identify opportunities for improved care coordination and high-risk patient identification.
Communicate high-risk patients’ needs and follow-up plans to community-based and hospital-based care coordinators.
Develop and maintain relationships with community-based providers to enhance transitions between the ED and community.
Apply knowledge of emergency medicine, utilization management, and community providers to patient care plans, and inform ED providers of relevant implications and opportunities.
Assess continuing-care needs with patients’ families and/or caregivers.
Contact transfer and access departments, acute care hospitals, post-ED care facilities, and home health agencies to facilitate timely transitions.
Facilitate discharge plans requiring post-ED care.
Partner with ED social workers and staff nurses to facilitate transitions of care.
Participate in decisions to admit patients to assess admission appropriateness and help prevent unnecessary admissions.
Identify patients with or likely to have unmet insurance needs and communicate with or refer them to the ED social worker, appropriate departments, and inpatient care coordination staff.
Investigate and recommend alternative care delivery sites based on level of care and insurance benefits.
Contribute to utilization and improvement efforts and support improvements in quality, cost of care, and satisfaction outcomes.
Maintain a flexible work schedule to match availability to patient demand.