Transition of Care RN -- Labor & Delivery

Job Description :

Position Overview: The Transition of Care Registered Nurse (RN) serves as a pivotal member of the healthcare team, facilitating the seamless transition of patients from one healthcare setting to another, such as from hospital to home or from one level of care to another. This role requires a compassionate and detail-oriented individual who can assess patients' needs, coordinate post-discharge care, and advocate for continuity and quality of care throughout the care transition process.

Key Responsibilities:

1. Patient Assessment: Conduct comprehensive assessments of patients' medical, psychosocial, and functional needs prior to discharge from the hospital or healthcare facility, identifying potential barriers to successful transition and recovery.
2. Care Planning: Collaborate with interdisciplinary healthcare team members, including physicians, case managers, social workers, and therapists, to develop individualized transition plans that address patients' clinical needs, preferences, and goals.
3. Patient Education: Provide patients and their families with education on post-discharge care instructions, medication management, signs and symptoms of complications, and strategies for self-management of chronic conditions, promoting patient empowerment and adherence to treatment plans.
4. Care Coordination: Coordinate post-discharge services and resources, such as home health care, durable medical equipment, rehabilitation therapy, and community support services, ensuring timely access to necessary resources and continuity of care.
5. Medication Management: Conduct medication reconciliation to ensure accuracy of medication lists and identify discrepancies or potential interactions, collaborating with pharmacists and healthcare providers to optimize medication regimens and minimize risks.
6. Follow-Up: Schedule and facilitate follow-up appointments with primary care providers, specialists, and other healthcare providers as indicated, advocating for timely access to necessary services and ensuring continuity of care.
7. Communication: Serve as a liaison between patients, caregivers, healthcare providers, and community resources, facilitating clear and effective communication to promote collaboration and coordination of care across settings.
8. Documentation: Maintain accurate and detailed documentation of patient assessments, care plans, interventions, and outcomes in electronic health records, adhering to institutional policies and regulatory requirements.
9. Quality Improvement: Participate in quality improvement initiatives aimed at enhancing the transition of care process, identifying opportunities for improvement, and implementing evidence-based practices to optimize patient outcomes.
10. Patient Advocacy: Advocate for patients' rights, preferences, and needs throughout the care transition process, ensuring that their voices are heard and respected, and addressing any concerns or barriers to care access and continuity.

Qualifications :

• Registered Nurse (RN) licensure
• Bachelor of Science in Nursing (BSN) preferred
• Certification in Case Management (CCM) or related field preferred
• Strong clinical assessment and care coordination skills
• Excellent communication and interpersonal abilities
• Knowledge of healthcare systems, community resources, and care transition best practices
• Ability to work collaboratively in a multidisciplinary team environment
• Commitment to patient-centered care and advocacy
• Experience in case management, care coordination, or transitional care preferred