Overview and Responsibilities
Assists in the development, implementation and function of a heart failure transitional care program. Interacts with physicians and ancillary personnel across several disciplines including physicians, nurse practitioners, case managers, social workers, and nurses to coordinate care for the heart failure patient. Duties include initial screening for the heart failure patient, education, appropriate resource utilization, care transitions from inpatient to ambulatory care setting, and follow up patient contact.
Initiates patient contact upon obtaining referral from physicians, and or identification of new heart failure patient admission.
Coordinates access to services and education for the heart failure patient.
Participates in activities to improve health care delivery.
Provides patient, family, and/or staff teaching/education.
Coordinates heart failure transitions of care.
Participates in ongoing educational activities.
Completes assigned goals.
Performs other duties as assigned.
3 years clinical nursing practice required. Heart failure experience helpful.
Experience in adult education, Strong clinical, communication, and organizational skills are critical.
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