Evaluates Centers of Medicare/Medicaid Services (CMS), TJC and American Heart Association/American Stroke Association (AHA/ASA) and/or Det Norske Veritas (DNV) core measures and implements improvement strategies. Provides continuity of care by ensuring smooth transitions between care settings. Develops a relationship with the patient and their multidisciplinary team to facilitate and/or navigate through subsequent treatment and follow-up to reflect continuity of care. Completes a nursing assessment to identify the patient's individualized needs and collaborates with the multidisciplinary team and other departments to develop an interdisciplinary plan of care. Supports the patient and family by providing education, addressing psychosocial needs, advocating, providing continuity of care and identifying barriers to care. Navigates patients and family members throughout the diagnosis, treatment and follow-up of the patient throughout the continuum of care. Performs comprehensive chart review to determine: type of stroke, etiology of stroke, disease modifiers, medication review (both current inpatient medications and home medications), past medical history related to stroke diagnostics, and compliance with TJC, DNV, CMS, AHA/ASA and American Association of Neuroscience Nurses (AANN) best practice guidelines. Collaborates with multidisciplinary care team to facilitate treatment plan based on AHA/ASA and AANN guidelines. Identifies, evaluates, and acts to resolve any potential barriers to delivery of care and timely and appropriate discharges. Facilitates discharge planning and post-discharge care management needs. Provides expert clinical advice to the multidisciplinary team in designing collaborative teaching plans/programs and in planning/providing patient/family education and discharge planning including wellness and health maintenance within designated specialty. Evaluates, selects or designs patient education materials on specific disease site programs. Provides education and outreach programs to patients, Aurora staff and to members of the community. Coordinates timely, seamless, evidenced based care across the care continuum resulting in best patient outcomes. Assists leadership in developing program vision, goals and objectives. Assists in the development, implementation and maintenance of quality programs that include best practice patient care outcomes including quality of life, and enhanced patient loyalty. Must be able to demonstrate knowledge and skills necessary to provide care appropriate to the age of the patients served. Must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify each patient's requirements relative to his/her age-specific needs, and to provide the care needed as described in the department's policies and procedures. Age-specific information is developed further in the departmental job standards.
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Job Type
Full-time
Career Level
Mid Level
Number of Employees
11-50 employees