Triage-Nurse

External Community Memorial Hospital•Morrisville, NY

7d•Onsite

About The Position

Provides service to patients of Community Memorial Hospital's five outpatient Family Health Centers (Morrisville, Waterville, Munnsville, Cazenovia, and Sherrill). Responsible for managing a patient’s successful transition from hospital and long-term care to primary care services. Manages the post-acute care of patients at risk for poor health outcomes, frequent emergency room visits, and hospital readmissions. Coordinates with the CMH Care Coordination team to identify hospitalized high-risk, complex patients for program enrollment and communicates with primary care to promote and maximize care coordination. Serves as a member of the CMH Readmission Committee. Completes post-discharge workflow of telephonic follow-up within 48 hours, facilitating clinical care, patient access to appropriate services, referrals, and primary care appointments within 14 days. Focuses on medication reconciliation and adherence, identification and rectifying gaps in care, assessment and support of the patient’s ability to perform self-care, and coordination of post-discharge appointments and services. Communicates and coordinates with all provider(s) and member(s) of the care team as needed to minimize fragmented care. Advocates for patient(s) and supports clinical team(s) to ensure delivery of appropriate, evidence-based care. Provides specialized nursing treatment, development of care plans, and education to patients while exercising discretion and independent judgment, following established policies and procedures. Uses a patient-centric, collaborative partnership approach to assist the patient with improved self-management. Utilizes proven processes to measure a patient's understanding and acceptance of the proposed plan(s), his/her willingness to change, and his/her support to maintain health behavior change. Addresses the total individual, inclusive of medical, psychosocial, behavioral, and spiritual needs. Involves the patient and their support systems (i.e., caregiver, family, etc.) in the decision-making process. Assesses the educational needs of the patient/caregiver as it relates to the disease process, alterations in function, and assimilation back into the home and community. Applies teaching and learning theories to assist patients and families with the physical and emotional impact of body changes and chronic illness. Monitors quality and effectiveness of interventions to the population by setting long-term and/or short-term specific, measurable goal(s). Accesses and systematically uses data from multiple sources such as patient medical records, claims, and program metric reports to target recipient(s) and provider(s) for outreach, education, and intervention. Provides clinical experience in an educator role for family health center nursing staff. Participates in the orientation of new nursing staff and provides expert coaching and guidance through both formal and informal one-on-one teaching with nursing staff. Facilitates Quality Improvement activities that educate and support nursing regarding evidence-based care for best practice/National Standards of Care (Adapted from CMSA, 2010). Collaborates with Practice Manager and FHC Administration team in quality/performance improvement programs and projects, product evaluation, outcomes evaluation studies, and/or clinical research.

Requirements

RN with three to five years relevant clinical nursing experience
Experience with pediatric patients
Experience with behavioral health patients
Experience with patients with chronic conditions
Organized and motivated by a fast-paced environment
Able to manage multiple tasks/projects simultaneously
Proficient in review and assess needs quickly
Strong with the use of computer software tools and data files
Comfortable with continuous change and self-initiating
Maintain strict confidentiality
Build effective and trusting relationships with patient/peers
Use motivational interviewing and active-listening skills when assessing patient conditions, problems and interests
Use conflict-resolution skills when reaching consensus about plans of care and treatment decisions
Demonstrate confidence, compassion, political savvy, as well as attention to detail to apply these skills as decisions dictate
Use data to analyze trends and to verify data
Ability to promote programs and services to community
Proficient in review of medical records and other patient care information

Responsibilities

Managing a patient’s successful transition from hospital & long-term care to primary care services.
Managing the post-acute care of patients at risk for poor health outcomes, frequent emergency room visits, and hospital readmissions.
Coordinating with CMH Care Coordination team to identify hospitalized high-risk, complex patients for program enrollment and communications with primary care to promote and maximize care coordination.
Serving as a member of the CMH Readmission Committee.
Completing post-discharge workflow of telephonic follow-up within 48 hours, facilitating clinical care, patient access to appropriate services, referrals and primary care appointments with 14 days.
Focusing on medication reconciliation and adherence, identification and rectifying gaps in care, assessment and support of patient’s ability to perform self-care, coordination of post-discharge appointments and services.
Communicating and coordinating with all provider(s) and member(s) of the care team as needed to minimize fragmented care.
Advocating for patient(s) and supporting clinical team(s) to ensure delivery of appropriate, evidence-based care.
Providing specialized nursing treatment, development of care plans, and education to patients while exercising discretion and independent judgment; following established policies and procedures.
Using a patient-centric, collaborative partnership approach to assist the patient with improved self-management.
Utilizing proven processes to measure a patient's understanding and acceptance of the proposed plan(s), his/her willingness to change, and his/her support to maintain health behavior change.
Addressing the total individual, inclusive of medical, psychosocial, behavioral, and spiritual needs.
Involving the patient and their support systems (i.e. caregiver, family, etc.) in the decision-making process.
Assessing the educational needs of the patient/caregiver as it relates to the disease process, alterations in function, and assimilation back into the home and community.
Applying teaching and learning theories to assist patients and families with physical and emotional impact of body changes and chronic illness.
Monitoring quality and effectiveness of interventions to the population by setting long term and/or short-term specific, measurable goal(s).
Accessing and systematically using data from multiple sources such as patient medical records, claims, and program metric reports to target recipient(s) and provider(s) for outreach, education, and intervention.
Providing clinical experience in an educator role for family health center nursing staff.
Participating in the orientation of new nursing staff and providing expert coaching and guidance through both formal and informal one-on-one teaching with nursing staff.
Facilitating Quality Improvement activities that educate, support, nursing, regarding evidence-based care for best practice/National Standards of Care (Adapted from CMSA, 2010).
Collaborating with Practice Manager and FHC Administration team in quality/performance improvement programs and projects, product evaluation, outcomes evaluation studies and/or clinical research.