Job Details
Job Summary:
Supports care coordination efforts for patients with heart failure under the supervision of cardiology and the heart failure team. Eligible heart failure patients will receive in-home visits during which their individual needs will be assessed, and a customized health monitoring and education program will be created. A diagnosis of heart failure requires a lifestyle change, and the CBHM nurses will help patients manage a care plan that is individualized to their environment and resources.
Nurses will serve in an expanded health care role to collaborate with specialists, members of the health care team, and patients/families to ensure the delivery of quality, efficient, and cost-effective health care services. Goal of integrating evidence-based clinical guidelines, preventive guidelines, and protocols, in the development of individualized care plans that are patient-centric and promote quality and efficiency in the delivery of health care. Remote work will be permitted when home visits are not being performed.
Position Responsibilities: Collaborates with heart failure team leadership to lead population health initiatives
Perform in-home assessment during patient enrollment and in follow up
Follow up with patients via telephone call as needed
Collaborate with the cardiologists and nurse practitioners
Educate patients on their plan of care, prescribed medication, therapy, diet and exercise
Provide home-based care to patients with heart failure
Assesses health literacy of patients
Develops and implements patient education materials.
Examine patients, perform assessments, document progress and report changes to their physician
Coach family members on the patient's plan of care, dietary requirements, medications and home safety
Ensure goals are met and coordinate discharge from services
Coordinates with social worker with regard to community resources.
Serves as a clinical resource to practice staff.
Other duties as assigned.
Position Qualifications Required:Required Experience:
1-3 years of experience in care coordination. Experience working in physician practice preferred.
Required Education:
Graduate of an accredited school of nursing, BSN preferred
Training / Certification / Licensure:
Must have current NJ license, current CPR certification.