Patient Information Analysis:
- Uses assessment skills and appropriate risk assessment tools to identify patients with actual or potential health care needs that would require care coordination.
- Collaborates with patient/family in establishing mutual goals based on the patient's needs or problems.
- Evaluates, compares and interprets ambiguous and changing patient data.
- Explores patient's understanding and knowledge of current health status.
Patient observation and monitoring:
- Applies nursing judgment to determine level of care assigned or delegated.
- Uses knowledge of complex physiology to monitor, detect and anticipate early and subtle health status changes.
- Monitors, trends and records patient response to disease, illness, treatment.
- Coordinates care across the continuum (inpatient/outpatient/community) to assure appropriate utilization of clinical and community resources.
- Accountable for individualized plan of care and its delivery.
a) Applies expertise to solve problems, generate ideas, plan care, teach and create new services.
b) Assigns Standards of Care
c) Uses scientific background, knowledge of change theory, ability to work with an interdisciplinary team, psychosocial skills and creative strategies to ensure quality, effective, evidence based and cost efficient care for the patient.
d) Collaborates with patients about plan of care.
e) Guides development of multiple health care partnerships to achieve a positive health effect.
- Maintains purposeful therapeutic presence with patients based on nursing judgment.
- Provides care based on patient complexity and nursing judgment.
- Uses patient's perspective to support informed decision-making.
Promotes patient wellness and facilitates healing.
- Anticipates future needs and educates or refers to valid sources of information.
- Understands the patient's unique perspective and assures right education, right time, right environment for learning.
- Evaluates outcome of learning.
Delegation and supervision of assistive personnel.
- Delegates care based on situation.
- Fosters teamwork and respect.
- Assures effective use of staffing resources.
- Supports assistive personnel: Serves as a resource and holds assistive personnel accountable to complete delegated tasks.
- Ascribes to the ANA Code of Ethics for professional nursing practice.
- Commits to culturally congruent care.
- Commits to continuous learning.
- Participates in education of nursing colleagues and students.
- Commits to evidence-based practice and the conduct of nursing research.
- Commits to mission, vision and values of organization and to the profession of nursing.
Patient agent responsibilities:
- Creates an environment that assures patient safety.
- Promotes healing by creating an environment that conserves patient energy.
- Instills confidence in the patient's own ability to regain/optimize their own health.
- Partners with patient to help them integrate health status changes into their life.
Quality Improvement & Outcome Activities
- Continually evaluates the data to further refine the referral criteria to the RN CC caseload; provides feedback to staff to improve the referral process.
- Identifies actual or potential variances in standards of care and system problems that could lead to errors, delays in care, complications or increased cost.
- When appropriate, integrate care coordination with disease management efforts to achieve low cost interventions that achieve the greatest benefit and increase the accountability of patients for management of their disease.
Scope of the Job Age Specific Population Served Infant (less than 1 year)
Geriatric (65 years & older)
Adult (18 - 64 years)
Adolescent (13 - 17 years)
Pediatric (1 - 12 years)
OSHA Category Category I - All Employees in this job title have a reasonably anticipated risk of occupational exposure to blood and/or other potentially infectious materials. Position Qualifications Education and Experience: Required Associate degree in Nursing from an accredited college of nursing, as recognized by the Accreditation Commission for Education in Nursing or Commission on Collegiate Nursing Education. Bachelor's degree in Nursing, from an accredited nursing program (ACEN or CCNE), is required within six years of hire date. Graduates from nursing programs which are not accredited by ACEN or CCNE, must have at least one year of recent RN experience from an applicable care setting.
Desired Bachelor's degree in Nursing from an accredited college of nursing, as recognized by the Accreditation Commission for Education in Nursing or Commission on Collegiate Nursing Education, such as Clinical Nurse Leader or related healthcare field.
Work Experience: Required 5-7 years experience in nursing Desired Skills: Required Ability to... Computer Systems/Software/Applications basic computer skills Communication demonstrate effective customer service to internal and external customers Communication express or exchange ideas by means of the spoken word, communicating orally with others Comprehension understand complex problems and to collaborate and explore alternative solutions General - All Positions demonstrate commitment to quality and attention to detail General - All Positions conceptualize, think abstractly and continuously learn General - All Positions work as part of a team General - All Positions anticipate, think and respond quickly General - All Positions be flexible and adaptable General - Patient Care apply expert professional nursing knowledge General - Patient Care complete clinically-appropriate and timely documentation Leadership delegate Mathematics add, subtract, multiply, divide, record, balance, and check results for accuracy Organization organize and prioritize work schedules of others on short-term basis Organization time management skills Reasoning/Decision Making make decisions which have significant impact on the department's credibility, operations and service.