To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values-integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day.
Nurse Coordinator Smilow St. Francis
be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values-integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day.
The Nurse Coordinator for Oncology Multispecialty Care Centers (OMCC) is an integral member of an assigned Disease Team. The OMCC Nurse Coordinator focuses on: 1) navigating the patient and family across care settings according to the established patient care plan, 2) ensuring that the patient/family have appropriate information, understand and have the capacity to adhere to the medical plan, and 3) bridging between the various consultants, services, points of care encountered by patient/family. The primary roles of this provider are serving as a consistent primary contact for new patients and their families, partnering with the Intake Assistant to expedite entry of new patients into the system and collaborating with Disease Team members to ensure coordination of care across the continuum for the designated patient population. The OMCC Nurse Coordinator synchronizes patient/family care across care settings beginning with the initial referral and consultative visit and ending with handoff at a designated point determined by the specific disease team (will vary according to patient population and disease team preferences). The OMCC Nurse Coordinator interfaces with point of care staff in accordance with the plan for patient care, educates patients and families based on determination of learning needs, and communicates plan detail to patient/family, physicians, mid-level providers, others involved in the patient's care.
1. Clinical Practice: Patient/Family Assessment (Initial and Ongoing)
1.1. Collects Level II* patient data for new patients using established assessment form prior to initial visit to assess patient/family current and projected future needs; Note: Level II patient data includes physical and psychosocial history, current medical status, medication review, teaching/learning evaluation
1.2. Analyzes data compiled by the Intake Assistant to confirm completeness/accuracy and to determine appropriate provider and/or provider visit sequence; identifies and communicates gaps to ensure that all required data is available prior to initial consultative visit.
1.3. Evaluates patient/family response to medical, nursing and supportive care interventions at regular intervals (eg, following initial consultative visit, proposed treatment plan, initiation or modification of therapeutic plan)
1.4. Communicates initial and significant follow-up assessment findings to appropriate team members and documents according to policy.
2. Clinical Practice: Patient/Family Education
2.1. Develops a patient/family education plan based on assessment findings relevant to teaching learning topics, styles and the identification of special needs and preferences.
2.2. Provides patient/family instruction related to disease, treatment, potential adverse effects, symptom self identification and management, parameters for distinguishing between what can be self managed and what requires disease team intervention, how to contact the team.
2.3. Provides selected handout materials to patients/families to reinforce verbal instruction
2.4. Makes follow-up contacts (eg, by phone, email and visit) to ensure patient/family understanding of the plan of care, evaluate adherence levels and reinforce education provided
2.5. Documents patient/family response to information provided and communicates to the appropriate team members.
2.6. Coaches patient/family through diagnostic and therapeutic experiences to minimize anxiety and ensure adherence to medical plan; provides warm handoffs at various points but maintains contact with patient/family and point of care managers as patients move along the continuum.
3. Clinical Practice: Care Coordination and Patient/Family Referral
3.1. Alerts Tumor Board Coordinator to place patient on listing for treatment planning session and, if patient will be present, facilitates patient participation; attends treatment planning sessions and documents treatment plans formulated.
3.2. Interfaces with physicians, mid-levels, Practice Nurse and schedulers to ensure appropriate scheduling of laboratory and diagnostic studies, procedures, therapeutic interventions following initial consultative visit.
3.3. Uses findings of assessment data, team-based interactions and established triggers to initiate referrals for supportive care (eg, social work, nutrition, rehabilitation, psychological services) and community agency assistance (eg, home care, support groups, etc). Monitors and reports response to consultative intervention(s).
3.4. Liaises among and between point of care coordinators and supportive care clinicians (eg, Patient Service Managers, Clinical Care Managers, Social Work, etc) across care settings to ensure familiarity with patient case and special needs; ensures that patient safety needs are met during handoffs to point of care staff (eg, infusion, surgery, therapeutic radiation)
3.5. Participates in patient/family treatment planning conferences with MD as requested by patient and/or physician; accompanies patient/family to medical visits, interventional visits as desired by patient and as schedule permits.
3.6. Anticipates and/or identifies potential logistical, financial, personal barriers to patient adherence to visit schedule and therapeutic plan; makes other team members aware and interfaces with family members and any relevant internal and external providers to troubleshoot/develop a plan to minimize or eliminate obstacles.
4. Clinical Practice: Clinical Research
4.1. Identifies candidates for open clinical trials and communicates to physician, mid-level provider and assigned research nurse; collaborates with Research Nurses to ensure follow-through on clinical trials accrual of individual patients.
4.2. Anticipates and/or identifies potential logistical, financial, personal barriers to patient adherence to visit schedule and therapeutic plan as per protocol; makes other team members aware and interfaces with family members and any relevant internal and external providers to troubleshoot/develop a plan to minimize or eliminate obstacles.
5. Clinical Program Support
5.1. Oversees Intake Assistant performance by analyzing accuracy and completeness of data compiled on new patients and observing patient/family interactions; provides feedback to supervisor.
5.2. Participates in the development/revision of scripting for Administrative Staff (Intake Assistant, Clinical Secretary and Receptionists.
5.3. Collaborates with other team members to develop and implement clinical tools relevant to new patient access and navigation; evaluates tool effectiveness and reports to team.
5.4. Identifies and monitors program quality metrics relevant to patient access and navigation services; evaluates role effectiveness and reports to team.
5.5. Participates in team-specific Patient Safety and Quality monitoring and performance improvement action plans.
5.6. Serves as an ambassador for the assigned Disease Team, representing the team and its unique features to internal and external communities.
5.7. Participates in community outreach programming (eg, public education forums, support groups, health fairs, etc) as appropriate to disease team marketing and strategic plan.
5.8. Reviews/provides content relevant to role and patient access for inclusion in staff scripting, website and print materials for distribution.
5.9. Role models service excellence behaviors, incorporates disease team strategic plan elements into clinical program development activities.
6. Professional Development
6.1. Sets and strives to meet annual goals for professional development
6.2. Achieves/maintains oncology nursing certification
6.3. Actively participates in hospital and disease team committees and projects
7. Addendum: When needed or as assigned, performs practice/clinic nurse function as outlined in Clinical Nurse in the Ambulatory Practice/Outpatient Multispecialty Care Center functional description/overview
Bachelor's Degree in Nursing highly preferred; Master's Degree in Health-related field preferred
A minimum of three (3) years experience in adult inpatient services, ambulatory oncology service or operating room. Oncology experience preferred
Connecticut RN license;
Connecticut RN license; Oncology Nursing Society certification (OCN, AOCN) desirable
Position is held accountable for collaboration and consultation, education, clinical practice, and research through yearly written evaluations.