Transitions of Care Nurse

Position Summary 

The Transitions of Care Nurse (RN) is responsible for acting as the medical lead for the Transitions of Care and Complex Care teams at Lawndale Christian Health Center.  The Population Health RN will serve as clinical lead of the TOC team. They will support LCHC patients who are hospitalized to obtain needed interventions at the hospital and to ensure effective follow up post-discharge with primary care team.  The Transitions of Care Nurse will use their clinical skills to support hospital teams in determining post-discharge plans to ensure best outcomes clinically for the patient. The Transitions of Care Nurse  will also serve as a lead in providing and supporting ongoing follow up for LCHC’s most complex, unstable, and costly subgroup of patients. 

Principal Duties and Responsibilities*

1. Transitions of Care 
   • Serve as clinical RN lead of TOC team- support LCHC medical patients who are hospitalized - visit in-person those who are at LCHC partner hospitals and provide support/context to inpatient team regarding patient’s care including assisting with speciality care coordination and follow up on equipment/home health needs.
   • Provide effective mobile interventions to support patients where needed- at the hospital, in the clinic, at patient’s home or in the community
   • Consult in on cases managed by other TOC team- use RN knowledge to assist them in supporting their patients.
   • Complete all needed health risk assessments to identify high risk population and develop plan of care for those patients
   • Complete post-discharge contact to patients after discharge from hospitalization and intervene where needed to ensure patient’s stability in community (chronic care education, medication reconciliation, referral to community organizations, pharmacy coordination)
   • Provide warm hand off to clinic care team to enable them to better support our recently hospitalized patients.
   • Support care team care management staff by developing plans of care for them to follow with patients.
2. Complex Care
   • Provide ongoing support to our group of most complex high utilizer patients through direct care management or support to care team CM’s.
   • Provide low-barrier outreach and engagement to better support LCHC “high utilizers” in engaging in care with LCHC
   • Complete all needed tasks to maintain strong relationship with our most complex patients. Work either in partnership with CM by supporting them or directly with patient. This could include tasks outside of regular RN practice- referral support, DME home health follow up, assistance with benefits etc. 

 Required Skills or Abilities*

• Ability to use the nursing process to guide patient encounters and care.
• Communicate effectively with patients in a manner that protects their confidentiality and is sensitive to their culture and to their physical/emotional/spiritual condition.
• Flexibility to adapt to changing or stressful conditions, including unanticipated changes to working schedules or locations.
• Good interpersonal skills are a necessity, including an ability to work well with the variety of ages, cultures, and temperaments represented among LCHC staff and patients, treating others with kindness and professionalism in all they do.
• Commitment to demonstrating personal integrity through punctuality, honesty, an ability to follow instructions, proper attention to detail in all work matters, and a willingness learn from others.
• Possesses the ability to work independently, take initiative, and set priorities in accordance with the needs and mission of the clinic.
• Demonstrates clear and concise written and verbal communication skills for communicating coherently and professionally with patients and co-workers.
• Conscientious of departmental and organizational policies and procedures, and able to embrace and personify the mission of the Lawndale Christian Health Center.
• Strong ability to be a clinical leader in the organization and guide and delegate to a team effectively and clearly.
• Ability to delegate appropriate tasks to medical support staff.

 Required Knowledge, Experience, or Licensure/Registration

• RN Licensure in the state of Illinois
• CPR Certification
• Clinical experience preferred, preferably in an acute care or triage setting
• Experience with care management of patients of various risk groups and chronically ill patient groups preferred
• Bilingual in English and Spanish preferred