Transitional Care Nurse, LPN

POSITION SUMMARY

Faculty and Residents from the University of Kansas School of Medicine--Wichita’s Internal Medicine Department provide patient care primarily through our clinic. We are dedicated to continuous quality improvement while providing high quality, efficient health care to patients. The Transitional Care Nurse will be responsible for managing KU Internal Medicine patients’ transition process from inpatient hospital care to outpatient care. Outpatient care includes discharges to intermediate and temporary care facilities including, but not limited to, KU MPA ambulatory care clinics, skilled nursing facilities (SNF), nursing homes, long-term care facilities (LTCF), and assisted living facilities. Inpatient care will be provided at Ascension Via Christi St. Francis (AVCSF) Hospital and Wesley Medical Center (WMC). It is expected the Transitional Care Nurse would round between one or both hospitals (as assigned) and work with the patients’ respective medical team and ancillary teams to coordinate each patient’s transition of care.

ESSENTIAL FUNCTIONS

General Responsibilities:

• Complies with hospital policies and guidelines required for privileging and accessing facilities
• Identifies patients eligible for Transitional Care Management (TCM) and enrolls appropriate patients into TCM program
• Works with KU Internal Medicine (IM) Hospitalist providers to identify patients who are not eligible for TCM but require ongoing follow-up care coordination through KU IM or GI clinics
• Manages Transitional Care patient dashboard
• Monitors all aspects of patient care including diet, physical activity, medication accessibility/afford-ability, and care coordination
• Works with patients, groups, or families to plan or implement safe and effective transition of care plans
• Schedules and confirms appointments for patients by coordinating with clinic office staff, ancillary providers, and primary care providers
• Determines best level of outpatient care for individual patients, i.e., requires PCP visit or interprofessional shared visit
• Attempts two phone calls to discharged patients within 2 business days post-discharge (if discharged home)
• Attempts two phone calls to discharged patients within 2 business days post-discharge from a temporary care facility (if notified of their discharge)
• Coordinates care with clinic staff, communicating patient needs and barriers to care
• Documents all patient encounters in the appropriate electronic medical records systems, maintaining accurate, detailed reports and records
• Maintains scheduling and event calendars
• Provides or arranges for training or instruction of auxiliary personnel as scheduled
• Engages in research activities related to nursing; if applicable

• Participates in clinic process improvement activities and team meetings to ensure efficient operations

• Reliable attendance and punctuality
• Performing other duties as assigned

POSITION QUALIFICATIONS

Certificates & Licenses:

• Kansas licensed LPN

Education: Associate’s degree (two-year college or technical school)

Experience:

• Minimum two (2) years nursing experience required
• Three to five years experience in clinical or community health settings preferred
• Previous experience in caring for chronic disease patients required
• Previous experience in Care Coordination, Case Management or Home Health preferred
• Experience with navigation of local medical and social support systems preferred
• Experience with health systems and data reports preferred
• Bilingual in English and Spanish preferred
• EHR experience required (we use eClinicalWorks)
• Microsoft Office experience is essential for database management and word processing