Nurse Navigator - Stroke Prg

New Haven, CT
Feb 27, 2019


Job Description

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.


The Stroke Center Nurse Navigator facilitates the multidisciplinary clinical system resulting in exceptional patient care and clinical outcomes. The Nurse Navigator is involved with patients, families and staff members across the entire stroke care continuum - from pre-hospital, Emergency Department, Intensive Care Units, recovery care units, to discharge planning and follow-up calls, outpatient clinics, and community outreach events. The Nurse Navigator improves patient preparedness for treatment through education and psychosocial suport while also facilitating interaction between patients, their physician(s) and referrals as appropriate. The Nurse Navigator assists in the development of appropriate educational materials and program monitoring to promote coordination of care and patient satisfaction. The Nurse Navigator assists the clinical and leadership team with program development, expansion and successful achievement of programmatic goals.

  • 1. Assists with all clinical and administrative aspects, initiatives and responsibilities associated with the Stroke program.
  • 1.1. Assists physician leadership with ongoing management of the Stroke Program.
  • 1.2. Assists nursing leadership with the development, ongoing management, quality and outcomes of the Stroke Program.
  • 1.3. Serves as a clinical leader and role model for the Stroke Program.
  • 1.4. Maintains excellent understanding of medical knowledge regarding cardiovascular and neurological disease entities.
  • 1.5. In collaboration with the medical team, coordinates the clinical care of patients with neurological strokes and/or diseases.
  • 1.6. Maintains knowledge of evidence based medicine.
  • 1.7. Assesses patient and family understanding of patient condition, goals of care and ongoing management.
  • 1.8. Provides patients and families with education regarding their disease process, medications, treatment and plan of care.
  • 1.9. Works with Care Management to ensure efficient transition of care to rehabilitation facilities and/or community healthcare agencies.
  • 1.10. Participates in daily stroke and/or transition of care rounds as required.
  • 1.11. As a member of the stroke team, assists with establishing protocols and guidelines for the treatment of acute stroke.
  • 1.12. Performs additional duties as requested.
  • 2. Provides support to patient caregivers through guidance, direction and support in both the inpatient and outpatient settings.
  • 2.1. Assists patients and families in understanding their diagnosis, treatment options and available resources.
  • 2.2. Serves as an essential link between patients and all other care providers.
  • 2.3. As members of the Performance and Quality Committee, continuously monitors and measures progress of interventions and outcomes.
  • 2.4. Partners with patients and families in addressing their concerns, issues, desires and needs.
  • 2.5. Facilitates the assessment, initiation and evaluation of patient and family education.
  • 2.6. Enhances the patient/family quality of life through assessment, teaching, communication, emotional support, spiritual support and the practice of family centered care.
  • 2.7. Participates in multidisciplinary conferences as it relates to Get-With-The-Guidelines-Stroke guidelines for discussion and incorporates into treatment planning.
  • 2.8. Facilitates appointments for consults and support services within established service standards, including social work, dieticians, physicians, etc.
  • 2.9. Responsbile for outreach efforts establishing and maintaining positive working relationships with physicians, nurses, social workers, rehab services, etc.
  • 2.10. Assists with planning and implementation of a safe discharge and transition of care.
  • 2.11. Maintains responsibility for post discharge phone calls and follows up as appropriate.
  • 2.12. Conducts follow up calls related to patient satisfaction; identifies trends and reports to selected committees in the hospital. Develops and implements corrective action as required.
  • 3. Maintains and prepares for compliance readiness related to ongoing Joint Commission Primary and Comprehensive Stroke re-certification.
  • 3.1. Maintains knowledge of Joint Commission certification requirements.
  • 3.2. Assists with preparing all necessary certification and recertification documents and remains current with stroke center regulatory guidelines, changes and updates.
  • 3.3. Represents YNHH at State and peer Stroke Center meetings as requested.
  • 4. Assists physician and administrative leaders with Stroke Center quality improvement process.
  • 4.1. Participates in department specific quality improvement activity relevant to program and role.
  • 4.2. Assists in achieving objectives for the Stroke Center and supports an action plan to accomplishe set goals.
  • 4.3. Assists with educating staff regarding the Stroke Porgram's quality improvement process.
  • 4.4. Participates in continuous performance improvement activities.
  • 4.5. Collaborates with multidisciplinary team to develop comprehensive plans to systematically document indications, appropriateness, complications and success of treatment.
  • 4.6. Assists Stroke Coordinator with data collections and maintenance.
  • 4.7. Supports YNHH High Reliability organization inititative.
  • 5. Collaborates with physicians, nurses and staff to assess educational needs of patients, families and community.
  • 5.1. Assesses needs and collaborates with physicians and clinical staff to develop and provide ongoing stroke education.
  • 5.2. Participates in stroke and neurovascular health awareness programs.
  • 5.3. Coordinates and provides community education on stroke awareness, prevention and treatment.
  • 5.4. Assists with providing education to community providers and emergency responders.
  • 5.5. Functions as a resource for providers and community agencies.
  • 5.6. Functions as a clinical resource for residents and nursing staff maximizing opportunities in the clinical setting for informal education of staff, patients and families.
  • 6. Medical record management.
  • 6.1. As requested, assists with data abstraction and statistics.
  • 6.2. Documents all patient and family interactions in the electronic medical record according to established protocols.
  • 6.3. Utilizes the navigator flow-sheet for the documentation of the multidisciplinary plan of care and achievement of patient goals.
  • 6.4. As requested, completes patient contact log daily to accurately reflect outreach activity.

    Other information:


    Bachelor's Degree in Nursing required; Master's degree in Nursing or Healthcare preferred.


    Three (3) to five (5) years experience in acute care, neuroscience rehabilitation or healthcare management required. Experience in a combination of the following will be considered: clinical care, clinical process improvement, outcomes management, case management and physician relations. Knowledge and understanding of standards related to the Joint Commission certification process and "Get With The Guidelines-Stroke" preferred. Excellent oral and written communication skills.


    Connecticut RN license required; BLS and ACLS certification required; SCRN certification within three years of hire.


    Candidate must be able to thrive in a fast paced, complex academic medical environment where the Nurse Navigator works as a valued member of the multidisciplinary team. Must possess understanding of clinical processes, organizational dynamics and process improvement. Must be self motivated, goal oriented and able to work independently. Must be able to work as a member of a multi-disciplinary team. Must have the ability to develop relationships and work collaboratively and effectively in partnership with patients, families, physicians, clinical staff, hospital departments, community and outside organizations. Must have excellent assessment, communication and organizational skills with the ability to manage and follow through on multiple priorities. Excellent critical thinking, analysis and assessment skills for successful process improvement planning and monitoring. Proficient in computer and data management. Must be flexible and able to quickly transition to needed roles across various care settings as described in the transition of care venues,

    Accountable for assuring patient needs are met throughout the continuum of care. Assist physicians and Stroke Center with addressing barriers to care, coordination of services and other psychosocial needs. Responsible for identifying gaps and/or trends in care and assisting Stroke Center clinicians and administration with implementing practice changes that support evidence based practice.

    High degree of interpersonal skills required; knowledge of community and its resources; ability to case manage; abiltiy to work in a team setting to achieve desired patient and program outcomes. Must be able to plan and prioritize daily activities. May exercise independent judgement referring complex situations to the Stroke Center clinicians. Responsibilities will include special assignments/projects as outlined by the Navigator Team Lead in collaboration with the Stroke Program manager.

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    Job Info

    Job: 5705

    Department: Stroke Program
    Category: Nursing-staff
    Sub Category: OTHER
    Status: Full Time
    Shift: DAYS
    Hours: 40.00