Description
The Hospital at Home Nurse Navigator (PART TIME) is responsible for providing high-quality discharge planning, care coordination, and follow-up care for patients involved in the UChicago Medicine's Acute Hospital Care at Home model. The Hospital at Home nurse navigator will act as a patient advocate, utilizing critical thinking skills to perform timely care coordination. Care Coordination will meet individual's unique healthcare needs and promote positive outcomes during the acute stay and for any additional follow up care that is required after discharge. The position requires care coordination competencies to explain and educate patients and caregivers on the unique care plan, technologies, and processes of the acute care at home model. Adheres to National Patient Safety Goals as appropriate, based on the level of patient contact this position requires.
Essential Job Functions:
Core Functions:
- Maintains the ability to work with a designated caseload and deal with rapidly changing priorities.
- Demonstrates the ability to collaborate with multidisciplinary teams for successful transitions to the home setting and when discharged from the model.
- Identifies, plans, and facilitates strategies to provide appropriate clinical health coaching to support patients with self-management of their acute and chronic disease and lifestyle changes to mitigate health risk once discharged from the Acute Hospital Care at Home model.
- Identifies patients who require community support and facilitates a comprehensive approach to the social determinants of health to help patients overcome obstacles that keep them from receiving the care they need.
- Ensures that all critical elements of the care plan and transition of care plan have been communicated to physician, multi-disciplinary team, patient and family including expediting teaching needs.
- Navigate patients and families across the continuum of the UChicago Medicine Hospital at Home phases of care.
- Monitor and escalate biometric data per UChicago Medicine Hospital at Home protocols.
- Conduct audio/visual patient care visits as directed by the care team and/or protocol.
- Ensure all interventions in the patient's care plan are implemented efficiently with a patient centered approach.
- Leverage the resources and expertise of the UChicago Medicine partners and supplier partners to implement collaborative workflows, standards, policies, protocols, guidelines and documentation systems to support safe, reliable, high-quality, evidence-based care with clinical protocols as the foundation.
- Adhere to the clinical protocols and be willing to obtain the necessary training to provide care within the context of the providing evidence-based care.
- Promote professional practice and a culture of safety; willingness to engage in process improvement efforts.
- Completes tasks related to transition of care outreach, documentation, and follow-up care.
- Clinical Roles and Responsibilities:
- Provide protocol driven assessment, care coordination and interventions as appropriate informed by UChicago Medicine Hospital at Home protocols for diverse patient populations.
- Exhibit sound clinical decision making and critical thinking skills.
- Maintain and practice in accordance with nursing guidelines per state and hospital regulations.
- Facilitate admissions to Hospital at Home utilizing UChicago Medicine Hospital at Home guidelines.
- Utilize nursing knowledge to identify, prevent and/or solve complex acute and/or recurring patient care problems.
- Share expertise with the multidisciplinary team and serve as a resource to staff in area(s) of expertise.
- Support research efforts to advance knowledge and promote evidence-based practice.
- Performs other duties as assigned and pays close attention to detail and accuracy of documentation of records along with proficient use of multiple databases and IT resources.
- Maintains ongoing member case load for regular outreach and management.
- Explain and educate patients and caregivers on the unique care plan, technologies, and processes of the acute care at home model.
- Must be comfortable with adopting new technologies and able to clearly articulate their use to patients.
Qualifications:
- Associate Degree required
- 5 years of Registered Nurse experience in an acute care setting.
- Must be able to communicate effectively in English.
- Demonstration of core competencies will be completed within 90 days.
Completion of all position-specific unit specific competencies within 12 months.
Licensure/Certifications:
- Current RN Illinois license.
- Current BLS certification upon hire, or completion within 30 days of hire required.
This is a part time position.
Benefit eligible
Every other weekend
8am-4:30PM-
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