Provide quality, clinical services to patients in various settings in the community. Patient care is delivered within organizational philosophy, policy and standards of nursing and community health practice. The responsibilities are performed in accordance with MGB Healthcare at Home and other applicable policies and standards of practice, utilizing thorough and timely electronic documentation and interdisciplinary communications. Skilled nursing care is provided in the form of assessment, teaching, treatment, documentation, and care coordination demonstrating high quality customer service and financial awareness.
Key Responsibilities
• MGB Healthcare at Home RN, is responsible for rapid phone triage and assessment of complex medical patients across the healthcare continuum.
• This role will interface directly with patients, providers, paramedics, and primary care teams, virtually as needed to facilitate plan of care.
• This nurse will require exceptional critical thinking skills and clinical judgement, working with this higher acuity population.
• Excellent communication skills are required to establish meaningful patient/nurse relationships using remote platforms for communication.
• Patient/family teaching is an essential element of this position to ensure patient and family understand plan of care, diagnosis, med teaching and follow up if needed.
• Discharge planning (that includes the patient, family and multidisciplinary clinical care team and accesses community resources) is initiated on admission and evaluated on an ongoing basis for optimal patient safety and outcomes.
• Patient information and change in status/plan of care is communicated to care team, including the APP &/or MD as needed, and documented timely.
• Medications are reconciled accurately and timely at admission, discharge, and transfer, and any changes are integrated into the patients care plan and documented in the electronic health record.
• Referrals are made to other disciplines and to appropriate community resources to maximize patient safety and outcomes.
• Patients are identified for multi-disciplinary case conference/rounding as needed.
• Patient information is prepared and communicated to appropriate care team members and others as needed via effective communication methods.
• Staff meetings, competencies, mandatory compliance training and educational meetings are attended regularly. Clinical initiatives and special training is supported.
• Software is updated by maintaining the latest version of software applications as defined by the IS department.
• Point of Care standards are adhered to for submission of data, no later than midnight of the day of the visit/admission, and sooner if patient condition warrants. Exceptions to the standard must be reported to the Clinical Manager or designee in the same time.
• While this role will be virtual to support the needs of MGB Healthcare at Home Emergency Services, this RN will also learn foundations of clinical operations via exposure to MGB Healthcare at Home field clinicians and Navigator to provide full clinical landscape.
• This RN will also be cross trained to represent Healthcare at Home Nursing in the AMC Emergency Departments, in the role of Care Transition nurse, as needed.
• This RN will interact with the PCP offices referring patients to Healthcare at Home Emergency Care as well as, the Healthcare at Home RN navigators referring patients to Healthcare at Home Observation.
• This RN will triage the cases/calls and if appropriate accept the patient into the program, call the patient to consent to visit and arrange visit with paramedic dispatch. There will be some data entry into EPIC and communication to the PCP in EPIC.
• Nurses will provide proactive rounding and patient checks on the patient, while in Observation status.
• This role will assist with facilitating all facets of care with patients while in observation, including med reconciliation as well as discharge review and teaching from the program as needed. RN will always have an ED MD and team support as back-up.
• There may also be some slight research component to the job, as position evolves.Education/Degree Requirements
• Graduate of an approved School of Nursing
Licensure, Certifications or Registration
Required: Current Massachusetts license as Registered Nurse
Experience
• Minimum of three years previous nursing experience in acute or emergency setting required.
• Emergency Department Nursing Preferred
• Must have extensive triage experience, virtual triage a plus.
• Ability to work with various computer software applications and technologies required.
• Strong interpersonal and customer service and ability to work with a diverse population
• Ability to communicate effectively in writing, verbally and electronically
• Ability to work as a member of an interdisciplinary team of health care providers
• Ability to organize and prioritize work.
• Ability to work independently, be self-directed and adapt to unpredictable circumstances.
Summary
36 hour rotating days M-F
hours 8am-8:30pm
every 3rd weekend/ 2 holiday rotation
Physical Environment
Classification is Hybrid, however, primarily will work remotely and will cross train to cover as the transition of care nurse representing Healthcare at Home in the MGH/BWH Emergency Department. Every 3rd weekend and 2 Holiday rotation
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