POSITION SUMMARY:
The Transitions of Care Nurse for the HARP (Hospital readmission Reduction program) works with relevant stakeholders to identify and engage adult patients in care management with a focus on enhancing patient health and well-being, increasing patient satisfaction and reducing health care costs. The nurse works with inpatient and community-based staff to engage eligible patients and follow patients enrolled in the HARP program, coordinate discharge plans with the inpatient teams and family members and for patients who are readmitted to the hospital or present to our emergency room, identify any medical or social barriers to thriving in the outpatient setting.
The HARP program is a BMC-based program that follows high risk patients who have been discharged from BMC for 30-60 days post discharge. The team consist of nurse practitioners, community health workers and program leadership. It provides care management through home and community-based visits and phone calls. We support patients in meeting medical and behavioral health needs as well as social determinants of health needs. Our aim is reduce hospital readmissions.
Candidates for this role must have excellent interpersonal skills, clinical expertise in conditions prevalent in the Medicare population (Congestive Heart Failure [CHF], pulmonary disease, cancer, frailty, etc.), patient education and engagement skills, and the ability to work independently and collaboratively.
The nurse works at BMC on the inpatient floors and integrates with inpatient care operations – documenting in local medical records, participating in care planning efforts, etc. to ensure seamless care planning for patients while also serving as the link to continuing outpatient care. By complementing existing care teams on the inpatient and outpatient side, the nurse serves a critical role in connecting the dots across care providers and community agencies
Main responsibilities will include: assessing high-risk patients and understanding and communicating their post-discharge needs; collaborating with other members of the HARP team to create and coordinate cohesive care plans; participation in appropriate triage and prioritization of patients to post-discharge programs; engagement in creative problem-solving around discharge planning; and, providing patient education to increase patients’ ability for self-management and shared decision making.
Compensation will be based on a salary/incentive plan.
Position: Transition of Care RN Complex Care Manager (HARP)
Department: Pop-Health Care Management
Schedule: Full Time
ESSENTIAL RESPONSIBILITIES / DUTIES:
Key Functions/Responsibilities:
- Identify and recruit eligible and appropriate patients for HARP program based off an Epic worklist in collaboration with supervisors and local clinical site leaders
- Collaborate with patient and care team to develop patient-centered care plan, with particular focus on chronic disease management, social determinants, transitions of care and advanced care planning (HCP, MOLST)
- Visit hospitalized patients prior to discharge ortransfer to establish relationship, identify needs and clarify potential discharge plans; provide educational support and coaching.
- Collaborate with community partners, such as VNA agencies, caregiver programs (PCA, ADH, AFC), DME providers and social service agencies
- Collaborate with outpatient HARP team to execute outstanding patient care tasks after hospital discharge.
- Facilitate interdisciplinary consultation on patient’s behalf through participation in rounds, team meetings and clinical reviews
- Use reflective, empathetic language and open-ended questions to understand the patient priorities
- Has knowledge of common chronic medical conditions presented in the population served and is able to:
- Educate the patient on their medication conditions and medications, and build their self-management skills;
- Use motivational interviewing to promote behavioral change;
- Assess, triage, and rapidly respond to clinical changes that impact discharge and/or plan of care
- Participate in weekly care planning meeting with HARP team
- Provide expertise and clear recommendations on safe discharge plans for at-risk patients.
- Actively participate in planning and growth of program with relevant stakeholders as needed
- Comply with established metrics for performance and adhere to documentation and work flow standards
- Maintain HIPAA standards and confidentiality of protected health information.
- Adhere to departmental/organizational policies and procedures.
- TOC nurse will work full-time at the clinical site of care in person
- Follow established hospital infection control and safety procedures.
- Perform other duties as requested or needed.
Metrics:
- Patient ED and inpatient visits
- Total medical expense
- Patient satisfaction
- Clinical outcomes
- Provider satisfaction
- Avoidable admissions
- Program enrollment
Other duties as assigned
JOB REQUIREMENTS
Qualifications:
Education:
Preferred/Desirable:
Experience:
A minimum of two years of clinical experience is preferred, with care management, inpatient and geriatrics experience preferred
Preferred experience:
- Experience working with vulnerable patient populations
- Geriatrics experience
- Home care or ambulatory care nursing
- Motivational interviewing
- Clinical experience working with patients with multiple complex health issues
Certification or Conditions of Employment:
Licensed to practice professional nursing as a Registered Nurse in the Commonwealth of Massachusetts.
Competencies, Skills, and Attributes:
- Excellent interpersonal skills and ability to work collaboratively
- Self-management skills, including ability to prioritize and set patient-centered goals
- Experience with electronic medical records; Epic experience preferred
- Excellent written and verbal communication
- Able to maintain professional boundaries
- Ability to work with diverse, safety-net population
- Skilled at engaging difficult to engage patients—build rapport, trust
- Creative problem solver
- Ability to adapt to changes in healthcare delivery at local and systems level
- Extensive knowledge of healthcare systems and community resources
- Ability to leverage systems and resources for improved patient outcomes
- Strong organizational and time management skills
Working Conditions and Physical Effort:
- Regular and reliable attendance is an essential function of the position.
Equal Opportunity Employer/Disabled/Veterans
