Posting Note: The Nurse Specialty Care Coordinator will be providing care coordination and case management services to families and patients for whom psychological trauma, emotional trauma and/or other social determinants of health have had impact. Will also be heavily involved in program development and community outreach for this population. Should have experience working with patient and families with Adverse Childhood Experiences and Toxic Stress and be comfortable with the principles and practices of trauma informed care. Self-motivated and organized person preferred.
This position utilizes advanced critical thinking to develop, implement, and evaluate an individualized plan of care that educates, empowers and optimizes patient outcomes throughout all transitions within the continuum of care. It provides leadership, clinical expertise /integration and functional direction to team members in order to ensure quality and continuity of patient services. Serves as the expert resource within a specialty area and participates in assessing specialty population needs and health outcomes. It facilitates continuity of care using nursing process, interprofessional collaboration, coordination of and access to appropriate health care services and community resources.
- Family-Centered care that focuses on the need of the child first and values the family as an important member of the care team
- Excellence in clinical care, service and communication
- Collaborative within our institution and with others who share our mission and goals
- Leadership that set the standard for pediatric health care today and innovations of the future
- Accountability to our patients, community and each other for providing the best in the most cost-effective way.
Nursing Process/Direct Care
- Implements nursing process of assessment, planning, analysis, intervention and evaluation, incorporating physical as well as psychosocial and developmental needs of designated patient populations.
- Focuses on a patient population, individual patient or caregiver's needs.
- Utilizes multiple means of communication including telephone triage, in-person interaction and the use of current and future technologies.
- Documents patient encounters and required follow-up.
- Communicates relevant clinical information to the physicians and team to optimize patient outcomes and goals.
Management of Patient's Condition
- Acts as partner, advocate, and advisor, assisting and supporting patient/family in the optimal management of their own health care, respecting their culture and values, individual needs, health goals and treatment preferences.
- Provides patient/family education that focuses on health promotion, management of health issues, and prevention of complications.
- Utilizes a variety of motivational strategies to effect positive patient/family outcomes.
- Delegates teaching components to staff prepared to teach and/or intervene in clinical settings.
- Prepares patient and family as they transition through the care continuum.
- Facilitates communication between patient, family and interdisciplinary.
Operations of Clinic Services
- Works collaboratively with unit / medical leadership to provide guidance and direction to staff by taking an active role in planning, decision-making, and communication to healthcare team of issues affecting the interdisciplinary team, quality of care, and integration of patient care activities.
- Provides clinical expertise that promotes coordinated specialty services.
- Assesses staff education needs and provides staff leaning opportunities relevant to patient / family specialty population.
- Assists in the investigation of significant incidents or identified risk, and partners with leadership to identify opportunities for improvement.
- May organize operations of clinic site to assure compliance with necessary service requirements of identified population or specialty program.
- Utilizes professional, regulatory, and governmental agency standards to guide care of patient population.
Continuity of Care
- Facilitates continuity of care using nursing process, interprofessional collaboration, coordination of and access to appropriate health care services and community resources.
- In collaboration with the multidisciplinary team, refers patients to optimal health services within and outside the organization and across the care continuum.
- To assure optimal care and coordination, supports patient and family in transitioning across the care continuum: hospital based services, community based services and other health care professionals.
- Facilitates transition from pediatric to adult care as appropriate.
Assessing Effectiveness of Services and Monitoring Specialty Population Needs and Outcomes
- Evaluates effectiveness of specialty care services with attention to target population quality indicators, such as unplanned admissions, patient satisfaction, and health / illness / injury outcomes.
- Maintains skill and knowledge proficiency/competency within specialty area.
- Maintains accurate records to support data analysis and reporting.
- As needed prepares accurate, required reports for granting agencies, specialty national health initiatives, and hospital quality initiatives.
- Regularly reviews research based literature to improve clinical care outcomes and support quality improvement efforts, as well as compliance with regulatory bodies.
- Facilities adherence to national standards as appropriate.
- Promotes the development of community awareness of disease process as appropriate to the focus of the clinical specialty program.
- Provides community education.
- Participates in relevant community events.
- Performs miscellaneous job related duties as requested.