Transitional Care Nurse

Signature Healthcare Defuniak Springs , FL 32433

Posted 4 months ago

RN Transitional Care Nurse
7a-7p

Every Other Weekend

Chautauqua Rehabilitation and Nursing Center is a 180-bed skilled nursing facility located in the beautiful and historical community of DeFuniak Springs in the Florida Panhandle. Surrounded by tall pine trees, the facility has two completely enclosed courtyard areas that allow residents to enjoy being outside, and provide a great place to visit with loved ones. The Chautauqua team has provided over 30 years of consistent quality care to the local and surrounding communities. Services include skilled nursing care, in house therapy, respiratory services, specialized dementia care, certified wound care, and an outstanding quality of life program.

Are you looking for a little more creativity, challenge, and growth opportunity in your workday? Didn't think it was possible? Might be time to reconsider.

At Signature HealthCARE, our team members are permitted no, encouraged to employ their talents and abilities to solve problems. Our culture is built on three distinct pillars: Learning, Spirituality and Intra-preneurship. But this isn't just hollow corporate sloganeering. Each pillar has its own staff and initiatives, ensuring that our unique culture permeates the entire organization.

Oh, by the way, we're an elder care company. Our mission? To radically change the landscape of long-term care forever.

We're currently hiring for the position of Transitional Care Nurse

Essential Duties & Responsibilities:

  • Meet physical and sensory requirements stated below, and be able to work in the described environment.

  • Identify and participate in process improvement initiatives that improve the customer experience, enhance work flow, and/or improve the work environment.

  • Understand and assist in coordinating the TransitionalCARE program within the facility.

  • Communicate with clinical nurse and review hospital accepted referrals to identify immediate needs and overall clinical status of the patient.

  • Review current medications of the patient from the hospital.

  • Obtain clinical report from the hospital nurse prior to transition.

  • Brief the primary care team, nurse, CNA, and Nurse Practitioner (NP), prior to admission.

  • Ensure that all necessary equipment and medications are available prior to patient arrival.

  • Collaborate with clinical liaison and admission team to assist with completion of the nursing Transitional Readiness Form.

  • Reconcile all medications (home and hospital) with the current physician orders.

  • Review and manage medications related to current formulary and corroborate with the attending physician.

  • Review Advance Care Planning with the patient and family.

  • Lead the Full Life Conference within twenty four (24) business hours of admission.

  • Coordinate the transitional home planning with social services within twenty four (24) business hours of admission.

  • Start the personal health record (PHR) and coordinate with NP.

  • Conduct coaching sessions related to the PHR prior to transitioning home.

  • Coordinate with the MDS coordinator the overall plan of care of the patient within the first twenty one (21) days.

  • Develop and conduct patient/family teachings on chronic disease management (CHF, COPD etc.).

  • Conduct clinical rounds with the primary care team and the NP within twenty four (24) business hours of admission.

  • Conduct daily clinical rounds of all patients in the transitional care unity to ensure positive patient experience.

  • Conduct transitional counseling within twenty four (24) business hours of admission, as requested.

  • Notify the primary care physician upon admission.

  • Notify primary care physician of transition and schedule the first physician visit after discharge from the facility.

  • Review and reconcile the PHR with the patient and family prior to discharge.

  • Conduct weekly follow-up phone calls to review clinical status, etc. after discharge with the patient and family for the next thirty (30) days.

  • Conduct Stakeholder in-services related to chronic disease management.

  • Collaboratively work with the MDS coordinator related to current clinical condition and plan of care.

  • Other special projects and duties, as assigned.

Job Requirements:

  • Bachelor's degree in nursing required or actively working towards obtaining; Master's degree in nursing preferred.

  • Licensed Practical Nurse (LPN) or Registered Nurse (RN) in good standing with required current state license.

  • Minimum of three (3) years related experience with at least two (2) years of medical/surgical.

  • Must have a current/active CPR certification.

  • Certification in case management, medical/surgical or chronic disease management required or commitment to achieve within one (1) year from date of hire.

  • Experience in case management, physical assessment and chronic disease management required.

  • Effective verbal and written English communication skills.

  • Demonstrated basic to intermediate skills in Microsoft Word, Excel, Power Point and Outlook, Internet and Intranet navigation.

  • Highest level of professionalism with the ability to maintain confidentiality.

  • Ability to communicate at all levels of organization and work well within a team environment in support of company objectives.

  • Customer service oriented with the ability to work well under pressure.

  • Strong attention to detail and accuracy, excellent organizational skills with ability to prioritize, coordinate and simultaneously maintain multiple projects with high level of quality and productivity.

  • Strong analytical and problem solving skills.

  • Ability to work with minimal supervision, take initiative and make independent decisions.

  • Ability to deal with new tasks without the benefit of written procedures.

  • Approachable, flexible and adaptable to change.

  • Function independently, and have flexibility, personal integrity, and the ability to work effectively with stakeholders and vendors.

Signature HealthCARE is an Equal Opportunity-Affirmative Action Employer Minority / Female / Disability / Veteran and other protected categories.


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Transitional Care Nurse

Signature Healthcare