Transitional Care Registered Nurse (TOC RN)
Saratoga Springs-NY-12866-United States
Summary of Position: The Transitional Care RN (TOC RN) is responsible for managing a patient’s successful transition from hospital to home. They are accountable for developing, implementing and evaluating transitional care interventions for Saratoga Hospital Medical Group (SHMG) patients. The TOC RN is responsible for managing hospital readmissions and working with complex and varied patients and situations.
The TOC RN will identify hospitalized SHMG patients and complete a post-discharge workflow. Post-discharge workflow includes identification of discharged patients, anticipation of potential gaps in care, education to patient/caregiver(s), telephonic follow up with patient/caregiver(s), medication reconciliation and adherence assessment, management of acute and chronic disease states, assessment of patient’s ability to perform self-care/instructions, coordination of post-discharge appointments and services (DME, Home Health Care), and coordination of other care.
The goal is to reduce the challenges that patients face post discharge and reduce hospital readmissions.
Primary Job Responsibilities:
- Identifies SHMG patients inpatient discharge status from Saratoga Hospital, other area hospitals, Skilled Nursing Facilities, Rehabs, and other higher levels of care.
- Identifies patient/caregiver educational needs. Ensures that patient/caregiver has adequate information and understanding to participate in and complete the transition of care planning.
- Conducts a comprehensive assessment of patient/family abilities and goals. Assesses complexity of care needs and potential/actual issues or gaps in care for discharged patients.
- With the above information develops, implements and evaluates a transition of care plan for each discharged patient.
- Initiates and maintains communication with patient/caregiver, physicians, social worker, care team leaders, staff, nurses, care management, and other disciplines.
- Completes a comprehensive medication reconciliation post discharge, updating patient’s electronic medical record to reflect correct medications and dosage.
- Assists patient/caregiver in arranging post-discharge medical/community referrals, such as appointments for follow up, home care referrals, or other services.
Minimum Qualifications: Registered Nurse required; BSN preferred. Two years working in Physician Practice setting preferred. Experience working with electronic health records, MEDENT preferred. Strong communication and conflict resolution skills.
PI274234868
