Job Description

JOB SUMMARY:
The Clinical Transition Specialist will conduct a comprehensive patient/family assessment and admission review of individual patients that present to the Emergency Room to ensure appropriateness of the care setting and timely implementation of the plan of care. The nurse will work directly with the Emergency Room MD/RN/Patient/Families to establish a plan of care and assist in implementation to facilitate a positive patient outcome. This role will work directly with outside resources to ensure patients a safe discharge plan.

EDUCATIONAL REQUIREMENTS
Associate's degree or diploma Nursing

CERTIFICATION & LICENSURE REQUIREMENTS
Registered Professional Nurse (RN) License Illinois upon hire. Accredited Case Manager Certification within 3 years.

EXPERIENCE REQUIREMENTS
Three (3) years clinical experience

ADDITIONAL REQUIREMENTS

• Attend and satisfactorily complete all required continuing education regarding the care of acute stroke patients

SKILLS AND KNOWLEDGE
Case management experience preferred


ESSENTIAL FUNCTIONS:

• Meet with patients and families, talking over the plan of care with the medical care team, and the use of the nursing process to assist patients and families through the emergency room experience.
• Provides early identification of high-risk patients and their needs.
• Provides identification of patients for whom standard of care treatments could be safely rendered at home.
• Works collaboratively with physicians, primary nurses, care team leaders, staff nurses, social workers, other care giving disciplines and patients/families to develop, implement, and evaluate a plan of care for the patient.
• Demonstrates ability for complex clinical decision-making.
• Collaborates with medical staff to recommend and arrange post-acute care including outpatient care, home health or other community agencies as indicated.
• Advocates for patients and families within the health care system. Including: Encourage pt/families to consider their goals of care. Work collaboratively with provider to determine appropriateness of Palliative or Hospice care. Be able to give an overview of services provided by Hospice and Palliative care. Share contact information for Palliative care and Hospice agencies. Make referrals for Hospice if pt will be admitted. Encourage pt/families to plan for future needs. Discuss options of community services, home DME, private duty care givers, and safety monitoring devices to help pt remain in their home. Promote Assisted Living facilities as prevention to injuries and admissions to IP and ECF.
• Collaborates with the medical team to ensure appropriate level of care should the patient need admitted.
• Monitor for frequent admissions or ED visits. Work with out patient care coordinator and/or PCP to develop a plan of care to avoid ED visits and hospitalizations.
• Provide early identification of high-risk patients and their needs.
• Critically evaluates and analyzes physical and psychosocial assessment data.
• Demonstrates ability for complex clinical decision making.
• Leads, coordinates and facilitates patient progression throughout the continuum

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