Serves as a patient and family advocate by being the point of contact as the patient/family prepare for transition to an outpatient dialysis clinic as well as arrive at next level of care. Assists with the medication reconciliation process by assessing the discharge medication plan for accuracy, completion and duplication. Ensures that the transition care plan is appropriate (meets all needs), comprehensive (all inclusive) and coordinated (communication) between levels of care and nephrology office. This role will work in collaboration with the greater Care Management Team and will be implemented for patients need dialysis only. Dialysis patients followed are defined as those needing new outpatient hemodialysis placement or return referral for outpatient hemodialysis. Assist with those patients possessing significant social determinants, behavioral, psychosocial and/or clinical variables which contribute to increase risk of safety, quality of care and avoidable, unnecessary readmissions. The role of the dialysis nurse care manager spans from during the patient's inpatient stay to 3-5 days post discharge. Assisting with Emergency Admissions back to Outpatient Hemodialysis Ensure inpatients avoid Dialysis on day of discharge. Impact on LOS and Readmission Rates Patient Education regarding dialysis Working with the other nurse care management counterparts to coordinate care and remove barriers. Services covers all patients who need dialysis when they leave the hospital. Assesses and intervenes at the bedside with patients needing dialysis after admission. Manage complete case management for identified New HD start patients. Cross-campus support at the Medical Center and Blodgett Hospitals in Grand Rapids, MI.
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Job Type
Full-time
Career Level
Mid Level
Industry
Religious, Grantmaking, Civic, Professional, and Similar Organizations
Number of Employees
5,001-10,000 employees