PURPOSE OF POSITION:

Serves as clinical liaison and encompasses coordination of care across the continuum for select populations. The Discharge RN (DC RN) is responsible for bridging the acute with the traditional episode, promoting positive and effective transition through modeling and facilitating new behaviors and self-management skills. The DC RN applies the process of assessment, planning, implementation, monitoring, evaluation, and coordination of care to meet the patients' health care needs across the continuum in collaboration with health care team members to ensure safe, quality, and cost-effective care. The DC RN must provide efficient, quality service always. The DC RN will accomplish this goal by conducting a home visit for patient discharged from hospital.

RESPONSIBILITIES & EXPECTATIONS

• Collaborates with hospital care delivery team, RN Care Coordinators and Social Workers as they identify patients at high risk for readmission to formulate plan of service and care across the continuum
• Responsible for oversight of discharge education in the home setting
• Meets with identified population to establish communication while in the home setting to foster a relationship and promote goal setting throughout the entire episode of care
• Maintains active communication with patient as designated by health population management initiative, displaying a flexible and innovative approach to health management
• Promotes teaching and ensures understanding of disease process via teach back
• Promotes/enhances patient -provider communication.
• Collaborate with all disciplines in the acute setting, to carry out ordered services
• Continues those efforts through active and ongoing communication with next level of care providers, supplying needed information, both written and verbal, to promote positive outcomes
• Functions as resource for patients regarding community outreach and support systems
• Promotes patient wellness through anticipating future needs, and education
• Utilizes tracking tool for actions, interventions, and outcomes
• Monitors and generates reports on decided key indicators
• Actively participates in development initiatives that support the strategic plan for population health management
• Participates in regular department meeting forums
• Fosters role of advocacy promoting positive care outcomes in fiscally responsible manner
• Promotes patient wellness and facilitates healing
• Practices Ethical Conduct:
  • Demonstrates honesty and integrity in all functions and relationships
  • Maintains Aultman standards of confidentiality, including HIPAA privacy guidelines
  • Complies with policies and procedures always
• Meets acceptable attendance and punctuality expectations (excluding FMLA)

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, disability, or veteran status.

WORKING CONDITIONS:

• Hours of operation are 8:00 AM to 5:00 PM, Monday through Saturday, of which an eight-hour shift is assigned. Off Shift coverage as indicated. On-call hours to be assigned as appropriate.
• Lunch and break periods must be coordinated with other staff members to maintain adequate office staffing during departmental operating hours.
• Sitting/standing/moving about intermittently during working hours.
• Requires driving and making home visits
• Subject to frequent interruptions and changes in priority of duties throughout the day.
• Works with highly confidential data, information, and situations.

PHYSICAL REQUIREMENTS ADDENDUM

PURPOSE: To identify specific functions job requirements and work environment factors that could affect job performance.

O = Occasionally = 0- 33% of the work shift or 0- 32 repetitions.

F = Frequently = 34-66% of the work shift or 32-200+ repetitions.

C = Constantly = 67-100% of the work shift or 200+ repetitions.

N = Not essential job requirement.

C Standing

C Walking

O Lifting (70 pounds)

O Carrying (70 pounds)

O Pushing (70 pounds)

O Climbing with (70 pounds)

O Stooping/Bending

O Twisting/Turning

O Kneeling/Squatting

O Crawling

O Reaching Up/Reaching Forward