Nurse Navigator Rheumatology Clinic

The Patient Navigator provides assistance to patients and family members in assigned area. Based on physical, mental, and social assessment skills, the Navigator works in collaboration with staff and physicians on the coordination of appropriate referrals and resources to meet the needs of the patient being actively treated and upon discharge.

Functions as a liaison between acute and sub acute providers in incorporating assistance with care needs post discharge. Assists with the coordination of evidence based best practices to promote positive patient outcomes following discharge. Provides education and emotional support to the patient and family. Coordinates efforts in the prevention of readmissions based on quality delivery of care at all levels.

Responsibilities include, but are not limited, to the development, collection and analysis of data into specific dashboards utilized to enhance and coordinate the needs of the appropriate patient population.

Responsibilities

• Clinical Practice and Care Management
• Provides individualized, appropriate care in collaboration with staff members. Assists with the development of a patient-specific plan of care based on the goals of treatment and patient's needs.
• Works with patient and significant others to determine treatment and rehabilitation goals for desired outcomes based on the developmental needs of the patient.
• Assist with collection of specified data in evaluating the quality of care provided.
• Facilitates patient throughput in the admission / discharge / transfer process.
• Serves as a clinical resource to all members of the interdisciplinary team.
• Communicates and coordinates critical information related to risk issues to staff and physicians to ensure patient safety in the acute and sub-acute setting.
• Performs physiologic / psychosocial assessments to assist with the development of an individualized plan of care based on specific needs of the patient.
• The formulation of individualized plans of care considers patient's education and discharge planning needs. Prioritizes the delivery of care to the individual needs including cultural / ethical / and spiritual needs
• Participates in the planning of routine transitional health care needs (i.e. treatment options, patient placement options, end of life care (LaPost) discussion and options.
• Adapts planned education and information to individual patients and families by modifying teaching strategies or content. Integrates education during the delivery of care. Collaborates with patients / families to identify realistic desired outcomes based on developmental needs and restrictions.
• Actively advocates for patient rights and identifies potential conflict.
• Identifies variances from expected outcomes based on assessment and evaluation.
• Evaluates patient outcomes and make revisions in the plan of care.
• Delegates and request assistance from members of the interdisciplinary team in coordinating to the needs of the patient while being actively treated and upon discharge.
• Documents interventions and referrals in patients' chart and further follow up calls as indicated
• Collaboration and Partnership
• Consistently communicates / collaborates with the health care team members, patients, and family members to maximize resources and outcomes.
• Communicates, collaborates with community resources to enhance the continuum care to meet the specific needs of all patients and the specific needs of the geriatric patient.
• Maintains knowledge regarding program initiatives based on the geriatric population / needs and incorporates the outcome of the team / committees work into practice.
• Provides education to staff team members based on the developmental needs / limitations of the geriatric population.

Qualifications

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