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 primary role of the Heart Failure Nurse Coordinator role is to provide outpatient nursing care and the ability to apply and implement evidence based care. The HF coordinator must possess leadership skills necessary to implement processes for improvement of care delivery of the disease management process through the health system. Additionally the RN coordinator must stay current on regulations regarding HF readmissions, reimbursement and mortality standards in HF care. Knowledge of the health system and appropriate sites of care, delivery models and roles of various providers is beneficial.
- 1. Coordinates initial patient contact with disease manager at sites throughout heath system and acts as consultant for disease management program.
- 2. Maintains medical information and contact with patients/families and referring physicians. Conveys pertinent medical information in collaboration with the attending physicians and/or fellows to patient's primary and referring physicians and insurance providers.
- 3. Consults with payors, financial counselors and case managers to determine how best to address issues which may arise regarding patient benefits and medical reimbursements.
- 4. Facilitates diagnostic and/or treatment follow-up by participating regularly in rounds with the provider team.
- 5. Collaborates with the patient's nurses, as well as other members of the health care team regarding current medical plan of care. Attends interdisciplinary meetings, discharge planning rounds and family meetings as a representative of the service. Functions as a nurse resource to the staff for patients on the service and consultation for patients seen by the service.
- 6. Maintains inpatient follow-up by assessing patient needs, concerns and questions, and provides education and support. Collaborates with the appropriate individuals to facilitate the transition and coordination of follow-up after clinic visits, and/or follow-up by consulting services. Communicates with referring and primary physicians following patient discharge.
- 7. Facilitate transfer by providing updated medical information, which includes a report of the patient and applicable details and continuing care plan arranged.
- 8. Participates in enhancing the professional development of nursing staff and other health care providers involved in the care of the patients. Facilitates self care of patients through patient and family education.
- 9. Functions as the educational resource to staff nurses and other health care providers in the disease unit and/or quality initiatives.
- 10. Collaborates physician and nursing staff on the development of Patient Care Standards at individual disease management locations.
- 11. Collaborates with nurse in assessing the learning needs of patients and their families and providing education support when needed.
- 12. Provides written information to patients and their families pertaining to illness or surgical procedures and develops teaching tools as needed.
- 13. Conveys information pertaining to hospital policy and procedure to resident staff faculty and other members of the service.
- 14. Serves as a primary contact for patient and family
- 15. Facilitates team approach to total plan of care
- 16. Performs ongoing assessment and management of care
- 17. Coordinates care of multiple providers across the care continuum
- 18. Assists in the coordination of the clinical program through interaction with internal and external contacts.
- 19. Participates in safety and quality improvement efforts
- 20. Facilities the integration of documentation and information systems
- 21. Assists in marketing and community outreach efforts
- 22. Assists in the coordination of the clinical program
- 23. As a member of the patient care team, provides direct patient care during clinic visits in collaboration with the house staff and nursing staff.
- 24. Facilitates the continued care of patients following discharge through consultation with patients/families and home care agencies.
- 25. Remains current regarding issues pertaining to the heart failure specialty to enhance clinical practice.
- 26. Attends weekly disease management conferences as indicated
- 27. Collaborates with research nvestigators and protocol personnel
- 28. Fosters academic and clinical investigation through participation in research projects in the specialty practice area and related fields of study. Participates in literature review, data collection and data entry.
Bachelor's Degree in Nursing
Requires strong background in cardiology, specifically, heart failure care,
CT RN license
Knowledge of physiology involving the cardiology, specifically, heart failure care. Excellent communication skills.