Job Offer: Transition of Care Nurse:
Transition of Care NurseSun River Health provides the highest quality of comprehensive primary, preventative and behavioral health services to all who seek it, regardless of insurance status and capability to pay, especially for the underserved and vulnerable. Sun River Health is a Federally Qualified, Non-Profit Health Center serving communities in Suffolk, Rockland, Orange, Dutchess, Ulster, Sullivan, Columbia and Westchester County. Sun River Health is currently seeking a full-time Transitions of Care Registered Nurse.
The Transition of Care will facilitate collaborative transition of patients from various inpatient settings (hospitals-ER/ inpatient, skilled nursing facilities etc). this job offer will ensure multidisciplinary communication, collaboration, and coordination to ensure that the patient is able to transition safely back to the community in which they reside. The Transition of Care Nurse will conduct risk assessments located on any clinical stays, develop a comprehensive care plan, and involve clinicians as needed and share accountcapability in patients' results. Any readmissions within 30 days must be assessed and an knowledge gained as to why this occurred and how this can be prevented in the future. Barriers to optimal health must be identified and plan of care (POC) developed and executed to address all issues. The RN will deliver care in conformity with Sun River Health's policies and within their scope of practice and will provide health services, education on illnesses and diseases including therapeutic interventions and preventive care.
» capability to navigate the electronic medical record (EMR)
» capability to register patients and make appointments in the EMR as needed.
» Collaborates with interdisciplinary teams and healthcare partners to assess patient needs and deliver care to identified population upon discharge from varying clinical settings
» Participates in multidisciplinary meetings as required.
» Completes assigned/appropriate competencies and trainings
» Promotion of proven guidelines to improve health practices to increase the well-being of the patient and their community in which they reside.
» Identify internal and community resources to enable coordination of services for TOC patients
» Facilitate bidirectional information exchange with hospital, community, and primary care provider/team.
» Develop and coordinate nursing care plan for high-risk TOC patients (i.e. frequent ER utilizes or recurrent admissions)
» Coordinate with internal stakeholders/care team members (providers, clinical support staff, social workers, care managers, site managers to ensure appropriate access is achieved for Sun River Health patients including but not limited to timely follow-up appointments (48-72hr post discharge)
» Regularly report results and trends to manager
» Accurately provide documentation regarding patient care or collaboration.
» Work with care team to develop strategies to reduce unnecessary ER visits and recurrent admissions
» Notify Sun River Health primary care provider/care team of critical findings
» Complete medication reconciliation and provide patient education to facilitate achievement of self-management goals.
» Identify follow-up needs from disease specific laboratory findings and communicate with PCP as indicated
» Serve as point of contact for TOC patients; provide guidance and support in the coordination of activities for TOC patients
Bachelor's Degree or Associates Degree in Nursing from an accredited nursing program; Current registration and active license as a New York State Registered Nurse; practice as a nursing care practitioner; CPR certification or completion of certification during employment; Fluency in written and spoken English. capability to see, hear and speak to clients.