RN - HF Transitional Care Nurse Coordinator - Congestive Heart Failure

Hartford Healthcare•Hartford, CT

About The Position

Heart Failure Transitional Care Nurse Coordinators participates in an expanded nurse role as an integral member of the Heart Failure Team. They are at the forefront of the Heart Failure Disease Management Program and work in a collaborative environment with strong patient-centered interdisciplinary teams, focused on a patient-centered care model in a richly diverse work space. The nurse coordinator must possess our institutional values of integrity, kindness, safety, nurse excellence, leadership, professionalism, and loyalty while providing high quality safe care. Under the direction and general supervision of the Heart Failure Program Manager, the registered nurse coordinator uses high-level critical thinking skills and expertise in the safe administration of various heart failure intravenous medications aimed at decongestion while also balancing and providing the framework of a robust comprehensive advanced heart failure management program. The Heart Failure Transitional Care Nurse Coordinator utilizes evidence based practices in accordance with the State Nurse Practice Act, policies and procedures of the hospital and as directed by the medical staff. With a goal of reducing readmissions and improving quality of life for patients, coordinators use expert knowledge and the nursing process to develop a plan of care which includes standards of practice to meet the physical, emotional, spiritual, cultural, and educational needs of the patient and family. The coordinator provides specialty and individualized care, implementing interventions including heart failure education, medication education, dietary education and on-going counseling, promotion of self-care, and adherence to a therapy plan.

Requirements

Bachelor of Science Nursing Degree required
Current Connecticut Registered Nurse License
Basic Life Support Certification by the American Heart Association
Ability to adapt and be flexible to the needs of the Comprehensive Heart Failure Program
Ability to communicate clearly
Ability to utilize advanced critical thinking and judgment to make safe recommendations to both the patient and provider on how to improve their health condition or symptoms.
Strong Clinical skills
Ability to concurrently manage multiple priorities

Nice To Haves

Minimum of 3 years’ acute care experience preferred.
Minimum of 2-5 years’ heart failure experience preferred.
American Association of Heart Failure Nurses (AAHFN) Certification (or must obtain within 6 months of hire).

Responsibilities

Independently obtains and performs assessments while safely triaging and guiding a patient’s clinical course.
Presents patient history and clinical presentation to a Provider.
Establishes, implements, and evaluates an individualized plan of care with timely and appropriate clinical advice and interventions.
Perform extensive review of medications and eliminates inadvertent inconsistencies across transitions in care.
Communicates effectively with Providers to validate and verify medications and ensure medication safety and improved effective medication reconciliation and follow-up care.
Facilitates coordination of care across the continuum and collaborates with Advanced Practice Providers and Physicians to utilize therapy protocols.
Performs IV and medication therapy, assessment, and evaluation of the patient
Participates in the overall program growth, referral base, outreach, protocol establishment and re-evaluation
Participates in research and present programmatic milestones and accomplishments in various venues
Leads heart failure support groups, educational sessions, and develops Heart Failure newsletters, and other activities/ materials as needed.
Coordinates the Heart Failure patient experience throughout the Hartford Healthcare continuum based on the individual needs of the patient.