Description
Position Summary:
The RN Acute Care Navigator is responsible for direct patient care focusing on: Care Progression/Care Coordination, Level of Care, Length of Stay, Readmission Prevention, Value Based Programs, Daily Transition Rounds (DTRs), Discharge Planning and compliance for their assigned caseload to ensure appropriate patient throughput. Compliance requirements include but are not limited to: Maintains working knowledge of Condition Code 44 Intervention, Second IMM, MOON/Observation Status notification, Advanced Directives, Beneficiary notices, and Patient Choice. The RN Acute Care Navigator is responsible for collaborating with patient's care team (Physicians, Nurses, Social Workers, Ancillary Services, Care Navigation Resource Center Coordinators, Contracted Vendors, etc.) and escalating appropriately to ensure their assigned patient receives exceptional care and avoids unnecessary delays in care progression or discharge.
Accountabilities:
*All duties listed below are essential unless noted otherwise*
1. Conducts in person Initial Assessment with patients/caregivers including identification of patient decision maker as appropriate, with goal of Initial Evaluation completion within 24 hours of admission.
2. Develops Discharge Plan (with associated contingency plan) within 24 hours of admission; updates, as appropriate.
3. Assesses patients to determine ability for self-care and to identify those most at risk for post discharge adverse health consequences without intensive discharge planning. Provides a discharge planning evaluation to those patients identified as at risk and upon the request of the patient, key stakeholders, members of the interdisciplinary team or the physician.
4. Conducts a comprehensive assessment of the patient's physical, psychosocial, spiritual, environmental, and caregiver status to identify post-hospitalization needs. Documents all findings in the EMR. Identifies patients most at risk for readmission without intensive discharge planning through information gathered on the admission nursing database, electronic medical record (EMR) predictive analytics tools, and proactive case finding.
5. Completes Readmission Assessment on readmitted patients.
6. Shares Readmission Risk score daily during DTRs; collaborates with interdisciplinary team to identify high risk patients whose risk score may not have indicated appropriately; implements interventions according to risk score.
7. Identifies transitional care barriers and collaborates in comprehensive, patient-centered care plan development. Reassesses patients and revises the plan as applicable.
8. Implements Discharge Plan; inclusive of Discharge Plan communication and confirmation and includes patients/caregivers in Discharge Plan development to gain participation, agreement, and accountability.
9. Stratifies assigned patients by Clinical, Financial, and Psychosocial risk factors and submits follow-up referrals, as appropriate.
10. Consults Social Work for complex discharges and psychosocial/SDOH needs.
11. Develops, documents, and communicates Care Coordination Plan, updates as appropriate.
12. Collaborates with UM team, as appropriate and applies clinical understanding of medical necessity criteria, patient status and discharge criteria and assists UM team by relaying potential changes in medical necessity/appropriate patient status/LOC.
13. Reviews necessary patient information, including lab and other test results and progress notes in patient health record daily.
14. Collaborates and actively engages patients and key stakeholders throughout interdisciplinary progression and coordination of care along with the discharge planning process to ensure a patient-centered plan and document accordingly.
15. Partners with physicians as appropriate for care progression, care coordination and appropriate length of stay and collaborates with other key team members to manage transitional care activities and communicate vital information.
16. Actively participates in DTRs and facilitates discussion of progression and discharge needs.
17. Establishes initial Estimated Discharge Date (EDD), updates, as appropriate.
18. Discusses EDD with patient and/or caregiver(s).
19. Validates EDD with care team (inclusive of Attending Physician).
20. Validates Discharge Plan with Interdisciplinary Team (Physician, Nursing, etc.); updates as needed.
21. Escalates issues to appropriate level of Care Navigation leadership and coordinates mitigation activities in a timely manner as needed.
22. Provides supplementing patient-centered education to patients and key stakeholders regarding disease processes, medications, treatments, diet, and nutrition, expected symptoms and when/how to seek additional help. Utilizes motivational interviewing and teach back techniques as appropriate.
23. Coordinates patient access to necessary services, including community and public health resources. Assists patients/caregiver in selecting a post-acute care provider by sharing data on quality measures and resource use measures that are relevant and applicable to the patient's goals of care and treatment preferences.
24. Ensures assigned patients have an identified Primary Care Physician (PCP)/Specialist and follow-up appointment (or appropriate follow-up plan) scheduled prior to discharge; if PCP not identified, exhausts all efforts to assign.
25. Ensures effective communication through the continuum to support ongoing progress toward identified outcomes.
26. Communicates necessary medical information to appropriate facilities, agencies or outpatient services for follow-up or ancillary care, including all essential medical information.
27. Serves as a supportive resource regarding payor information; educates interdisciplinary team and patients/caregivers regarding payor requirements and/or barriers.
28. Works in partnership with acute and ambulatory care team to follow patient through care continuum and ensures thorough hand-off to ambulatory Care Navigators/Care Managers or post-acute caregivers. Serves as an essential link for patients without a primary physician.
29. Ensures timely delivery of second IMM notification, as appropriate.
30. Maintains positive working relationships with all internal and external customers.
31. Attends applicable conferences, trainings, and meetings. Participate in quality improvement and strategic initiatives.
32. Completes special projects and other duties, as assigned.
Required Qualifications:
Education: Must have either a BSN, or 5 years of applicable nursing experience.
Skills: Must have a history of positive rapport with patients, families, physicians, and interdisciplinary team members. Relevant experience working with diverse populations. Must
Compensation Information:
$0.0 / - $0.0 /
Starting At: 0.0
Up To: 0.0
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