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RN-Transitional Care Services

Company Name:
Alexian Brothers Health System
Alexian Brothers Health System is proud of the fact that we continue to build upon values established more than 800 years ago. Although many things have changed with the times, our commitment to respect, compassion, and quality care--for every patient and every professional--remains as strong as ever. Our network currently consists of four hospitals, as well as our immediate-care and occupational health centers.
PRIMARY PURPOSE :
Under administrative direction and clinical supervision of an Advance Practice Nurse (Director of Quality Improvement), the Transitional Care Services Nurse performs direct assessment in the acute care setting, reinforces patient/caregiver education or disease self-management, promotes advanced care planning, and engages appropriate community resources, all in an effort to prevent hospital readmission. The role serves as a conduit between the acute care setting, primary and specialty care providers and community resources.
REPORTS TO:
Acute Care Director Quality Improvement
JOB FUNCTIONS :
Provides comprehensive in-hospital planning and home follow-up for chronically ill, high risk older adults with defined diagnosis.
Emphasizes coordination and continuity of care, prevention and avoidance of complications, through active engagement of patients, their families and caregivers in collaboration with the patients' physicians.
Assumes a leadership role in coordination and facilitation of outpatient services appropriate for each patient and their family in the defined population.
Engage in advanced care planning with patients.
Participation in the quality component of the readmission prevention program, including identification of key clinical and financial measures, while facilitating improvement strategies that address clinical outcomes.
Collaborates with hospital palliative care professionals.
Performs high risk assessment of all aspect of readmission and support with referral and collaboration of APN for further community follow up as needed.
Performs other duties and projects as assigned
MINIMAL JOB REQUIREMENTS :
Licensed as Registered Nurse by the State of Illinois. Geriatric training a plus.
At least two years demonstrated experience in a transitional care model preferred. Certification a plus.
High level of clinical assessment skills and medical decision making abilities.
Excellent interpersonal skills; ability to work with and lead a multidisciplinary team.
Ability to perform the essential functions of the job and to meet its functional and environmental requirements
Date: 2014-04-24
Country: US
State: IL
City: Hoffman Estates
Postal Code: 60169
Job Type: Full time

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