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 Transition of Care Nurse (TCN) practices within the Patient and Family Centered Care Model to assess, plan, implement and evaluate care for patients, coordinate with physicians and collaborate with interdisciplinary health care team to properly facilitate quality discharges that address both patient care needs and psycho/ social determinants of health.
Graduate of an accredited school of nursing (BSN)
Five (5) years experience on a hospital nursing unit Two (2) to three (3) years of case management experience preferred. Med-Surg experience required.
RN in State of Connecticut. Med-Surg, Palliative or Hospice Certification preferred.
Collaborates and coordinates with physician to Individualize discharge plan based on patients specific needs, external factors and risk around transitions of care. Develop and utilizes risk assessment tools to prioritize patients in need of disease specific intervention. Education for medication management and discharge instructions. Advanced organizational and communication skills. Ability to interact therapeutically with patients, families, physicians, case managers, social workers, co workers and community agencies.
May be exposure to infectious diseases. Will be exposed to physical, mental and emotional illness as well as end of life conditions and death. Moderate stress and risk of injury from patient care. Standing/walking for more than half of the day. Frequently bending, reaching, pushing, pulling, twisting and lifting. Must be able to assist pushing/pulling/lifting patients ranging from five (5) to three hundred (300) pounds.