Transitional Care RN
About The Position
The Transitional Care Nurse (TCN) is funded through the Nebraska Rural Health Transformation Program (RHTP) initiative 4.4b grant. The TCN will oversee day-to-day program operations, coordinate hospital-to-home transitions, and lead a Remote Patient Monitoring Program, stand up and physician oversight for clinical escalation. The TCN's responsibilities are operational and administrative in nature, including patient identification, consent, device provisioning, training, and coordination. The TCN aims to strengthen chronic disease management, reduce avoidable ED visits & readmissions, and improve care coordination among local providers. The program will prioritize patients with hypertension, diabetes, COPD, cardiovascular disease, and chronic kidney disease, as well as post-discharge monitoring for high-risk patients. The TCN will partner with vendors Care Base & Health Recovery Solutions to deploy RPM devices. The TCN will assist with patient identification, consent, device provisioning, training, and coordination. The TCN will collaborate with the interdisciplinary team to recognize eligible participants utilizing analytics, clinical huddles, and predictive metrics, targeting specific chronic conditions as outlined in the grant requirements. The TCN will use the High Risk for Readmission report from Epic to identify those who scored as high risk on admission and encourage Case Management, Nursing, Clinical Documentation Specialists, and Physicians to submit referrals. The TCN will review all patient information in EPIC and available office visit notes, applying knowledge of the patient's clinical condition and home needs to establish the transition plan for post-discharge monitoring. The TCN will review/retrieve discharge orders from nursing staff, document all patient and family interaction in the Epic medical record, and inform healthcare providers regarding the enrollment of patients into the RPM program. Following a review of the patient's medical record, the Transitions Manager introduces themselves to the patient within the hospital, explains the Transitions program, and clarifies what to expect.
Requirements
- RN License
- BLS Certification
- 1-3 years Clinical RN experience in an acute care setting
Nice To Haves
- Bachelor Degree preferred
Responsibilities
- Oversee day-to-day program operations
- Coordinate hospital-to-home transitions
- Lead a Remote Patient Monitoring Program
- Stand up and physician oversight for clinical escalation
- Patient identification, consent, device provisioning, training, and coordination
- Strengthen chronic disease management
- Reduce avoidable ED visits & readmissions
- Improve care coordination among local providers
- Partner with vendor Care Base & Health Recovery Solutions to deploy RPM devices
- Collaborate with the interdisciplinary team to recognize eligible participants utilizing analytics, clinical huddles, and predictive metrics
- Targets specific chronic conditions as outlined in the grant requirements
- Receive and respond to referrals using High Risk for Readmission report from Epic
- Encourage Case Management, Nursing, Clinical Documentation Specialists and Physicians to submit referrals
- Review all patient information in EPIC and available office visit notes
- Apply knowledge of the patients clinical condition and home needs to establish the transition plan for post-discharge monitoring
- Review/retrieve discharge orders from the nursing staff
- Document all patient and family interaction in Epic medical record
- Inform healthcare providers regarding the enrollment of patients into the RPM program
- Introduce self to the patient within the hospital, explains the Transitions program, and clarifies what to expect
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
