The Registered Nurse in this role is responsible for identifying patients eligible for the Hospital at Home (HaH) program and community hospital transfers and facilitating appropriate dispositions. Based in the Emergency Department, the RN collaborates with ED clinicians, Hospital Medicine, and outpatient providers to evaluate patient needs, determine HaH eligibility, and coordinate safe transitions to the optimal level of care including but not limited to community placement and hospital at home.
Job Description:Essential Functions & Responsibilities:- Evaluates patients in the ED or acute care setting needing admission for clinically appropriate level of care eg. HaH, community placement, or alternative approved pathway.
- Applies utilization management guidelines (inpatient v. observation v. outpatient) to evaluate for appropriateness of transfer or identify other disposition options
- Facilitates discussion with patients and their families/caregivers regarding options for ongoing care.
- Provides education and offer placement in the most appropriate setting based on clinical needs, capacity, and patient preference.
- Addresses patient, family and caregiver concerns and identified barriers to enabling acceptance of alternative care resources.
- Has knowledge base and provides appropriate education regarding care available at the offered site to patients that meet candidacy requirements
- Facilitates hospital at home admission ensuring appropriate documentation/information sent home with patient, HM Provider completes informed consent with patient, and helps connect patient with HaH staff to complete admissions process (social screening, equipment delivery etc.)
- Functions as the central point of contact for all stakeholders
- Liaises with hospital staff and providers to ensure safe care transitions.
- Assists with interfacility transfers in coordination with transfer center, when clinically indicated, ensuring timely and appropriate placement.
- Keeps patients, families and caregivers informed as the transfer process progresses
- Advanced patient assessment skills to determine acuity, stability and suitability for HaH, or alternative site for care delivery.
- Strong knowledge of acute conditions, their management, and natural history (medical and surgical with possible complex comorbidities).
- Ability to identify "Red Flags" for home-based care
- Strong understanding of inpatient care pathways and criteria for tertiary vs community vs HaH admission
- Ability to clearly communicate care plans, options and rationale to patients, families, and caregivers
- Ability to coordinate multiple patient evaluations and discussions concurrently
- Excellent medical documentation skills
- Ability to determine safest and most appropriate care setting for each patient
- Understanding of hospital workflow, bed capacity, and interfacility transfer processes to support efficient patient flow.
- Capably navigate complex health systems involving multiple stakeholders
- Strong interpersonal skills to work effectively with multidisciplinary care team and provide patient centered support
- Demonstrate cultural competency to build trust and provide tailored guidance
- Advocates for patients to ensure that placement aligns with both clinical needs and patient preferences
QUALIFICATIONS & EDUCATION:- Bachelor's degree required.
- License Registered Nurse required and Certificate 1 Basic Life Support required.
- 3-5 years' related work experience required.
- Experience demonstrating professional competence and leadership.
- Broad view of system operations.
- Experience with computer systems required, including web-based applications and some Microsoft Office applications which may include Outlook, Word, Excel, PowerPoint or Access.
PHYSICAL & MENTAL REQUIREMENTS:- Ability to walk, stoop, kneel, crouch, or crawl as necessary.
- Occasionally lift and/or move up to 20 pounds.
- Vision and hearing corrected to normal ranges as required for job performance.
- Mental agility to adapt to changing work environments and demands.
SCHEDULE & COMPENSATION:Pay Range: $38.11 - $98.61
The pay range listed for this position is the base hourly wage range the organization reasonably and in good faith expects to pay for this position at this time. Actual compensation is determined based on several factors, that may include seniority, education, training, relevant experience, relevant certifications, geography of work location, job responsibilities, or other applicable factors permissible by law. Compensation may exceed the base hourly rate depending on shift differentials, call pay, premium pay, overtime pay, and other additional pay practices, as applicable to the position and in accordance with the law.
