Registered Nurse Patient Care Coordinator, Comprehensive Care Clinic
Location: Nashville, Tennessee
Internal Number: 2206494
Registered Nurse Patient Care Coordinator, Comprehensive Care Clinic
Your Role: Assists in developing and meeting key Pillar outcomes and system improvement goals including financial, satisfaction, and clinical as the nursing component of the care coordination model. This position Improves outcomes by reducing all cause hospital readmissions and coordinating episodes of care among patients in a defined population or disease process. Participates in identification of appropriate patients; encourage patient and family engagement in self-care management; promote warm handovers to the next level of care by providing timely, pertinent information in a standardized way; conduct patient and family education on key elements of the patients' personal care plan by using the teach-back methodology and follow up phone calls; and assists the patient in navigating the healthcare system.
We are seeking hard workers who have a heart for caring for patients, who have the ability to work in a fast-paced environment and enjoy a collaborative team-based work setting.
The Pathways program is a nursing-led, interdisciplinary intervention designed to provide community and clinic-based care to ensure patients have the appropriate level of support to manage their HIV disease. This service is key to successful viremic control since patients with HIV are at higher risk for secondary burdens beyond their ability to control, such as childhood sexual abuse, HIV stigma, substance use disorder, etc.
Responsibilities of the Pathways Team include:
Provide patient education and follow-up with Antiretroviral Therapy (ART) and regimen changes
Collaborate with providers to be sure that the patient is adhering to the regimen prescribed
Collaborate with the VUMC Transition Management Office with hospital discharges. This may include but is not limited to IV antibiotics at home, home health, nursing home follow-up and transportation issues.
Provide assistance with obtaining prior authorization for patient medications.
Participate in antiretroviral (ART) conference on Tuesdays and Fridays.
Overcoming barriers to care by addressing social determinants of health such as stigma, abuse, health literacy, medication access, insurance navigation, transportation, housing, etc.
Care coordination with community-based HIV/AIDS Serving Organizations
The primary responsibility of this position on the Pathways team at the V-CCC is to provide intensive case management that includes:
Leads the Pathways program; coaches and guides team members
Liaises with community-based HIV/AIDS Serving Organizations
Coordinates community-based medical care under the direction of a medical provider
The Vanderbilt Comprehensive Care Clinic (VCCC), a nationally-recognized HIV Center of Excellence and a certified Primary Care Medical Home, is located at Vanderbilt Health's One Hundred Oaks campus in Nashville, Tennessee. The VCCC provides care for more than 3,700 active outpatients living with HIV from Tennessee and adjacent states. The VCCC has on-site psychiatric, adherence counseling, social work, and nutrition services. Patients with HIV/AIDS receive quality, comprehensive HIV care, regardless of their ability to pay.
This position is Monday - Friday (Days) 8:00 a.m. - 5:00 p.m.
View how Vanderbilt Health employees celebrate the difference they make every day:
Discover Vanderbilt University Medical Center:
Located in Nashville, Tennessee, and operating at a global crossroads of teaching, discovery and patient care, VUMC is a community of individuals who come to work each day with the simple aim of changing the world. It is a place where your expertise will be valued, your knowledge expanded, and your abilities challenged. It is a place where your diversity -- of culture, thinking, learning and leading -- is sought and celebrated. It is a place where employees know they are part of something that is bigger than themselves, take exceptional pride in their work and never settle for what was good enough yesterday. Vanderbilt's mission is to advance health and wellness through preeminent programs in patient care, education, and research.
Our Nursing Philosophy:
We believe highly skilled and specialized nursing care is essential to Vanderbilt University Medical Center's mission of quality in patient care, education and research. We believe nursing is an applied art and science focused on helping people, families and communities reach excellent health and well-being.
Coordinates the evaluation process of the defined patient population. May complete and document portions of the evaluation process, collaborating with other team members to ensure completion of all required information.
Supports patient access by serving as a liaison between the referring provider's office and Vanderbilt provider.
Interacts routinely and effectively with the clinical team to develop a collaborative plan for the coordination of patient care from the anchor hospitalization through the defined care episode.
Develops and manages the processes related to pre-admission and post-discharge care transitions; establishes relationships/clinical pathways with providers/agencies to optimize care for defined patient population.
Assists in the development and dissemination of patient education materials/information to include creation of customized medication grids with input from the pharmacist/team as needed.
Assists with discharge/transition planning in collaboration with the multi-disciplinary team, actively engaging outpatient care providers by sharing hospital course, concerns, pending test results, learning needs, partnership opportunities etc. Coordinates handovers including outpatient care coordinators (disease management teams), home health care nurses, cardiac rehab, skilled nursing facilities, etc.
Demonstrates reflective practice by constantly evaluating care coordination and supports the development of protocols for practice based on evidence
The responsibilities listed are a general overview of the position and additional duties may be assigned.
RN ACCESS PATIENT EDUCATION (ADVANCED):- Demonstrates uppermost levels of patient education in practical applications of a complex nature. Possesses mastery of knowledge, training, and expertise to be capable of successfully delivering treatment planning services across the care continuum. Takes a lead role in complex situations when there is a need to achieve results. Actively participates in outside professional organizations and forums.
NURSING PATIENT ASSESSMENT & EVALUATION (ADVANCED):- Demonstrates the uppermost levels of expertise in patient assessment and evaluations in challenging and complex situations. Conducts primary care patient interviews and physical examination. Often takes a lead role in complex patient care situations. Possesses expert knowledge, training and experience to mentor less experienced peers.
EVIDENCE-BASED PRACTICE (ADVANCED):- Recognizes, Implements, and evaluates practice changes based on published research. Demonstrates expertise in applying evidence-based practices to challenging and complex situations.
TREND ANALYSIS (INTERMEDIATE):- Demonstrates mastery of trend analyses. Can recognize the impact and take into consideration the effect of seasonality and randomness. Has analyzed trends in detecting patterns that could lead to future problems and in forecasting future demand periods. Has worked in several areas that might include sales, marketing, quality, finance and manufacturing.
Organizational Impact: Delivers projects/assignments that have a direct impact on goals/objectives of the unit/department that the job is in.
Problem Solving/ Complexity of work: Conducts extensive analysis of situations or data to resolve numerous, complex issues; may involve the input/work of others.
Breadth of Knowledge: Has in-depth level of knowledge within a professional area and working knowledge of other areas.
Team Interaction: May lead mid-sized projects; coaches and guides team members.
SUPPORTING COLLEAGUES (P4):
- Develops Self and Others: Invests time, energy and enthusiasm in developing self/others to help improve performance and gain knowledge in new areas.
- Builds and Maintains Relationships: Maintains regular contact with key colleagues and stakeholders using formal and informal opportunities to expand and strengthen relationships.
- Communicates Effectively: Recognizes group interactions and modifies one's own communication style to suit different situations and audiences.
DELIVERING EXCELLENT SERVICES (P4):
- Serves Others with Compassion: Seeks to understand current and future needs of relevant stakeholders and customizes services to better address them.
- Solves Complex Problems: Approaches problems from different angles; Identifies new possibilities to interpret opportunities and develop concrete solutions.
- Offers Meaningful Advice and Support: Provides ongoing support and coaching in a constructive manner to increase employees' effectiveness.
ENSURING HIGH QUALITY (P4):
- Performs Excellent Work: Engages regularly in formal and informal dialogue about quality; directly addresses quality issues promptly.
- Ensures Continuous Improvement: Applies various learning experiences by looking beyond symptoms to uncover underlying causes of problems and identifies ways to resolve them.
- Fulfills Safety and Regulatory Requirements: Understands all aspects of providing a safe environment and performs routine safety checks to prevent safety hazards from occurring.
MANAGING RESOURCES EFFECTIVELY (P4):
- Demonstrates Accountability: Demonstrates a sense of ownership, focusing on and driving critical issues to closure.
- Stewards Organizational Resources: Applies understanding of the departmental work to effectively manage resources for a department/area.
- Makes Data Driven Decisions: Demonstrates strong understanding of the information or data to identify and elevate opportunities.
FOSTERING INNOVATION (P4):
- Generates New Ideas: Proactively identifies new ideas/opportunities from multiple sources or methods to improve processes beyond conventional approaches.
- Applies Technology: Demonstrates an enthusiasm for learning new technologies, tools, and procedures to address short-term challenges.
- Adapts to Change: Views difficult situations and/or problems as opportunities for improvement; actively embraces change instead of emphasizing negative elements.
Vanderbilt University Medical Center is home to Vanderbilt University Hospital, The Monroe Carell Jr. Children’s Hospital at Vanderbilt, the Vanderbilt Psychiatric Hospital and the Vanderbilt Stallworth Rehabilitation Hospital. These hospitals experienced more than 61,000 inpatient admissions during fiscal year 2015. Vanderbilt’s adult and pediatric clinics treated nearly 2 million patients during this same period. Vanderbilt University Hospital and the Monroe Carell Jr. Children’s Hospital at Vanderbilt are recognized again this year by U.S. News & World Report’s Best Hospitals as among the nation’s best with 18 nationally ranked specialties. Vanderbilt University Medical Center is world renowned because of the innovation, work ethic and collegiality of its employees. From our health care advances to our compassionate care, Vanderbilt owes its accomplishments and reputation to staff and faculty who bring skill and drive and innovation to the medical center day after day. World-leading academic departments and comprehensive centers of excellence pursue scientific discoveries and transformational educational and clinical advances across the entire spectrum of health and disease.As t...he largest employer in middle Tennessee, we welcome those who are interested in ongoing development in a caring, culturally sensitive and professional atmosphere. Most of us spend so much of our lives at work, we want to be part of maintaining a workplace in which people support one another and encourage reaching for excellence. Many high-achieving employees stay at Vanderbilt because of the professional growth they experience and because of their appreciation of Vanderbilt’s benefits, public events and discussions, athletic opportunities, beautiful setting and, above all, sense of community and purpose.Vanderbilt and its employees share a set of mutual expectations that have been created with productivity, legality, fairness and safety always in mind. We believe that our investment in training and compensating employees multiplies in value when we enable individuals to deliver their best performance for the benefit of us all.