Nurse Practitioner Care Management Transition

Overview

The Transition APP Advanced Practice Nurse (APN) will reflect the mission, vision and values of Hackensack Meridian Health (HMH). Complies with all relevant policies and follows established procedures and protocols and will adhere to the HMH Code of Ethics and Corporate Compliance Program and be held accountable for their performance. They will be an integral part of the Care Management / Population Health team. Holds a minimum of a Master's degree and fulfills all the requirements and education to maintain active board certification, as well as the agreed upon terms of employment. Reporting to the Supervisor of Care Transitions, this role will function as part of a multidisciplinary health care team in accordance with the privileges approved by the credentialing committee to provide high-quality, cost-effective patient care within their scope of practice. Knowledgeable in acute disease management and possess strong clinical and critical thinking skills, as well as exceptional communication skills. They must be a true team player capable of and willing to support each team member. Collaborates with attending physicians throughout the organization in overall goal achievement in patient experience and outcomes. Provides clinical guidance to support the unit-based care managers, social workers and staff nurses. They will be a driving force to ensure patient hospital stay and care transitions are as smooth and as safe as possible, thus driving positive clinical outcomes, patient, family and physician satisfaction and preventing avoidable readmissions to the hospital. Closely works on discharge planning and length of stay projects as assigned and be held accountable.

Need 2-3 years experience as an Advanced Practice Provider, preferably in acute care setting.

Responsibilities

1. Develop ongoing positive, collaborative relationships with key stakeholders: physicians, hospital leaders, floor nursing staff, physician advisors, care managers, social workers, physical therapist, occupational therapist, speech therapist, dietician, home care, ancillary service providers, etc. (i.e., the multi-disciplinary team).

2. Collaborate daily with physicians throughout the hospital as well as other hospital leadership.

3. Actively participate in patient care on assigned floor(s).

4. Order and interpret laboratory tests and diagnostic studies/procedures in collaboration with the attending physician and consultants, as appropriate, according to regulation and scope of practice.

5. Demonstrate competent clinical skills by utilizing evidence based medicine and best practice guidelines.

6. In collaboration with the attending physician, help with clinical documentation as needed.

7. Monitor patient Central Lines, PICC Lines and Foley Catheters on assigned floor(s) to ensure they are indicated. Ensure all lines are removed when no longer indicated. If properly trained, remove lines when needed.

8. Review all patients on assigned floor(s) with Restraints Orders daily. Ensure the restraints are indicated and that the restraint order and documentation is compliant with Corporate Policy. Take necessary corrective action to fix any deficiencies. Ensure restraints are discontinued when no longer indicated.

9. Participate in patient and family care meetings with the Attending Physician, Patient Experience, Palliative Care.

10. Work with leadership on discharge planning, length of stay (LOS) and observation status initiatives and maintain constant communication via daily huddles, weekly and monthly meetings.

11. Ensures appropriate collaborative discharge planning, education and coordination of service needs are met on each patient to provide a safe transition to the appropriate post-discharge status and prevent a hospital readmission.

12. Identify an anticipated date of discharge and anticipates and identifies obstacles to the progression of care.

13. Aids in attempts to solve obstacles to discharge.

14. Assists with discharge planning process including; medication reconciliation, discharge instructions and prescriptions.

15. Collaborates with the Bed Management Team to facilitate discharges and discharge orders.

16. Identify patients with extended LOS and work to eliminate barriers in discharges on each floor as assigned by leadership.

17. Eliminate duplicative and unnecessary testing and defer non-essential testing to ambulatory setting in order to decrease LOS and avoid risk to patients inherent in prolonged stays.

18. Work collaboratively with faculty, hospitalists and private attendings in ensuring the high LOS patients are appropriately identified on the assigned floor. Maintain communication by daily huddles with the attending physician and resolve barriers to discharge.

19. Maintain communication with leaders of the discharge planning, LOS and observation status leadership by daily huddles, weekly and monthly meetings.

20. Report progress on discharge planning, LOS and observation status to the leaders of these projects.

21. Provides accurate, confidential, systematic and organized documentation of findings, recommendations/plan and education.

22. Medical record completion in a timely fashion with key elements of documentation consistent with sound medical principles.

23. Accurate documentation of all medical evaluations, diagnosis, procedures, treatment outcomes, education, referrals and consults consistent with the Joint Commission on Accreditation of Health Organization and state regulatory standards.

24. Assists in compiling data and reports as requested by hospital administration.

25. Participates in multi-disciplinary rounds on assigned floors providing necessary clinical, safety and care coordination information.

26. Develop/implement clinical care plans for each patient based on their specific needs. Enter necessary orders.

27. Participate in documentation of multi-disciplinary rounds patient care plan daily.

28. Participate in clinical and management huddles as requested

29. Evaluation of each new patient admission with complex medical/social issues for diagnosis, medications, and medical plan of care to ensure completeness, appropriateness and efficient coordination of care. 30. Where applicable, ensure that order sets and care pathways are in place and used.

31. Monitor each assigned patient's clinical progress. Track daily to ensure care planning and physician's orders are implemented.

32. Discuss with attending/consultant any issues interfering with the progression of care.

33. Identify any care that is potentially unnecessary or inappropriate.

34. Identifies and addresses obstacles to care progression and transition and escalates issues as appropriate.

35. Ensures quality of care and customer satisfaction and will communicate any team member issues that compromise patient care and satisfaction to the appropriate leader.

36. Actively participate in team and departmental meetings.

37. Attends bed management meetings as requested.

38. Participate in other hospital and corporate meetings as requested.

39. Prescribe medication safely and effectively in accordance with the recommended best practice, hospital policy, NJ regulation and scope of practice.

40. Provides education on medication as needed.

41. Obtain and Maintain Appropriate Medicare and Medicaid Certification for prescribing durable medical equipment (DME), home oxygen and other supplies where these certifications are required.

42. Follows standard of care and clinical guidelines by keeping current with evidence-based literature and publications, seminar attendance, professional organization membership, networking and with federal and state regulatory guidelines.

43. Participate in special projects as assigned by Hospital Leadership.

44. Other duties and/or projects as assigned.

45. Adheres to HMH Organizational competencies and standards of behavior.

Qualifications

Education, Knowledge, Skills and Abilities Required:

1. Master's degree in Nursing (MSN) or Doctorate Degree in Nursing (DNP).

2. Thorough knowledge and understanding of clinical protocol, procedures, and standards within area of expertise in acute patient care management.

3. Ability to work with autonomy and demonstrate technical leadership skills and advanced clinical and critical thinking skills when caring for acutely ill patients.

4. Highly developed verbal and written communication skills and the ability to present effectively to small and large groups.

5. Strong interpersonal skills and ability to work effectively at all levels in a collaborative team environment.

6. Enthusiasm and willingness to participate in teaching, learning and quality improvement initiatives to maintain a successful program.

7. Excellent written and verbal communication skills.

8. Proficient computer skills that include but are not limited to Microsoft Office and/or Google Suite platforms.

Education, Knowledge, Skills and Abilities Preferred:

1. Prefer 2-3 years of acute disease management in an Inpatient Acute Care Hospital setting as an Advanced Practice Nurse.

Licenses and Certifications Required:

1. NJ State Professional Registered Nurse License.

2. Advance Practice Nurse License.

3. AHA Basic Health Care Life Support HCP Certification and ACLS Instructor Certification.

4. Controlled Drug Substance/Drug Enforcement Agency Certificate.

5. Medicare Certification and Medicaid Certification within 3 months of entering position.

Licenses and Certifications Preferred:

1. Medicare Certification and Medicaid Certification.