Transitional Nurse Navigator - Pulmonary

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The Transitional Nurse Navigator, Pulmonary (TNNP), in collaboration with the medical care team, advanced practice providers, and the entire healthcare team, oversees and supports the pulmonary patient and their significant other(s).

The TNNP is a member of the healthcare team and is responsible for coordinating, communicating and facilitating the care of selected patients with primary pulmonary care needs.

The TNNP is accountable for a designated case load determined by the careful daily selection of eligible patients. They assess, plan, and facilitate, with patients / families and healthcare professionals involved in the patient's care to meet treatment goals, and arrange for the appropriate next steps.

Promotes safe and timely transition of patients from varying levels of care in the hospital and community.

A day in the life of a Transitional Nurse Navigator at Hackensack Meridian Health includes :

• Participates in the collaboration with physicians, nursing staff, and interdisciplinary team in the assessment, planning, implementation and evaluation of care for selected patients and their families.
• Screening : All patients who are admitted for medical care will be screened for potential eligibility to the pulmonary transitions of care program.

All eligible patients will be enrolled.

• Patient / Family interview : Meets directly with the patient / family to assess needs, based on assessment and prior evaluation from care coordinators / case management and develop an individualized needs assessment.
• Person-centered transitional care plan (TOC) development : Develops a TOC plan, in collaboration with the patient / family, patient caregiver, patient support persons and healthcare team that will provide maximum benefit for each patient.

Reassesses periodically and evaluates against care goals and the plan of care and, when indicated, the plan or goals are revised.

Completes all other necessary duties with attention to detail and in a timely manner.

• Educator : Provides appropriate patient and family education regarding diagnosis, treatment, and self-care management and documents outcomes in the medical record.
• Bidirectional communicator : Facilitates communication and coordination between members of the health care team and involves the patient / family in the decision making process, in order to minimize fragmentation of services, manage resources and remove barriers to the discharge plan of care.
• Safe transition and quality assurance : In addition to aligning with patient quality metrics, confirms the patient has a primary care provider, pulmonary providers upon discharge and refers appropriately to a primary care provider and / or pulmonologist if needed.

Works collaboratively with all members of the multidisciplinary health care team and community partners for timely and appropriate transitions to the next appropriate level of care, including transition to the TOC unit.

Ensures timely follow up appointments with appropriate care providers, post discharge.

Networking and resources : Maintains current and up to date information of community resources and refers patients to those community resources which will enhance patient's life and clinical outcomes.

Consults with other community agencies and committees to identify potential resources to support patients and their families.

Provides patients and families with community resources and discharge care coordination options. Will actively work to find community partners across the care continuum.

Documentation : Documents patient / family encounters, interventions provided, and communication delivered in the electronic health record.

The Electronic Health Record will reflect the needs of the patient, any education needed based on the patient's medical history, coordination of follow-up care, and referral to community services.

Medical records reflect that each patient's discharge plan is re-assessed in response to changes in patient's needs and Social Determinants of Health.

Quality assurance and program development : Participates actively on appropriate workgroups, and / or meetings. Is a positive problem solver.

Identifies and refers quality issues for review to the pulmonary / medical and transition of care team locally. Monitor readmission rates for Medicare and all payers, and implement needed performance improvement projects to improve scores in collaboration with the pulmonary / medical team.

• Other duties and / or projects as assigned.
• Adheres to HMH Organizational competencies and standards of behavior.< / sp
30+ days ago