RN – Cardiac Specialty Care Coordinator, Home Visits

The Specialty Care Coordinator acts as an advocate to assist disease specific high risk patient populations in navigating throughout internal and external systems in order to facilitate the diagnosis and treatment process. Applies the nursing process through assessment, planning, implementation, and evaluation of the patient in order to provide the optimal level of patient care.

• Assists patients in understanding diagnosis, treatment options, and resources available internal and external to the organization.
• Serves as liaison in planning care between patients, caregivers and multi-disciplinary health care providers.
• Provide education and informational resources to patient to optimize continuous and comprehensive care.
• Collects data and prepares various reports pertinent to department.
• Communicate with Extended Care Facilities when applicable.
• Provide education on the importance on medication adherence, vital sign monitoring, follow up appointments, and other activities to maximize patient knowledge of self-care and reduce avoidable hospital admissions.
• Rounds on high risk patients in the hospital to discuss follow up with the specialty care coordination program
• Participates in teaching a class on living with specifc disease processes on the inpatient setting
• Attends both specialty clinic meetings and mandatory meetings for the care coordination department.
• Conducts extensive follow up post discharge on patients in the program including medication reconciliation
• Utilizes EPIC to run daily reports for their population and document using standardized templates
• Participates in quality improvement initiatives as well as outside committees
• May perform patient visits to primary residence for additional education, medication reconciliation, and other nursing functions
• Works with high risk population admitted to the hospital, navigating the discharge plan of care and follow up. Continues to reach out to the High Risk Population for support and triage of patient needs