When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives.
POSITION FUNCTION:
The Orthopedic Nurse Navigator is responsible for developing, coordinating, and maintaining the care continuum for orthopedic patient populations.
Provides coordination of the continuum of care beginning before surgery, including Pre-Admission Testing, Peri-op Services, inpatient units, and post-acute. Assist in the planning, developing, and implementing program goals and operations.
Job Description:
DUTIES AND RESPONSIBILITIES:
Care Continuum Facilitation
· Develops and maintains cooperative relationships with the Orthopedic Surgeons, and relevant members of the health care team along the continuum of care.
· Coordinates, supports, and provides guidance for the patient scheduled for elective orthopedic surgery and their family/care partner throughout all phases of care.
· Regularly meets with physician practices and their office staff to maintain ongoing communication and follow-up.
· Serves as an advocate for the patient during the development and implementation of the plan of care.
· Rounds on all elective orthopedic surgical patient post-operatively to enhance patient satisfaction and ensure quality of care.
· Has an understanding of insurance plans (guidelines, policies, practices) and patient class and impact on throughput.
· Maintains knowledge of insurance plan changes and communicates impact on Orthopedic decision making.
· Investigates and assists in the implementation of best practice across the continuum of care.
· Appropriately shares information with relevant practitioners and/or health care organizations about the patient’s disease or condition across the continuum of care.
· Provides appropriate communication to relevant practitioners and/or health care organizations regarding changes in the patient condition and transitions in care.
· Documents patient care to support interdisciplinary coordination.
· Reviews the medical record to ensure inclusion of appropriate information in order to support coordination of care and the transfer of information between the sending and receiving organization.
· In preparation for discharge, discusses and plans with the patient, family/care partner, practitioners and support services the care, treatment, and services that are needed in order to achieve the mutually agreed upon self management plan and goals within the appropriate length of stay.
· Attends relevant meetings and provides program updates.
· Identifies patients who are readmitted within 30 days.
· Call patients and families to review the implementation of care plans. Referring patients to services frequently used in a clinic and specialized services as needed.
· Explain hospital/community-based resources to patients and families and provide documentation.
· Participates in relevant community education and events.
· Assessing patients for referrals to resources. Acting as a liaison with internal and community resources. May contact hospital and community resources to ensure access to services.
· May assist patients and families with scheduling multidisciplinary appointments. Reviewing
appointment schedule and appointment instructions.
· Coordinating logistics for plan adherence, such as appointment reminders and arranging transportation.
· Travels as needed.
Practice Standards
· Identifying patients with high readmission rates identifies root causes and implementing preventive action plan.
· Assists the Orthopedic interdisciplinary team in developing a standardized process originating in clinical practice guidelines and evidence-based practice to deliver or facilitate the delivery of clinical care.
· Assists in the regular review and update of orthopedic order sets and pathways.
· Participates in the initial and ongoing education of team interdisciplinary team members’ related to current orthopedic order sets and pathways.
Outcomes
· Collects and analyzes data to determine variance from the clinical practice guidelines and comparison to external data sources for comparative purposes.
· Participates in the use of aggregate data and information to develop and support decisions in performance improvement planning and activities.
· Ensures Hospital goals of LOS reduction, readmission prevention, and satisfaction improvement are monitored.
· Involves the interdisciplinary team and other practitioners across disciplines and/or settings in performance improvement planning and activities.
· Monitors and reports to leadership the indicators and incidents throughout the episode of care related to complications, patient self-management, patient education, patient experience of care and patient goal achievement.
General
· Appropriately assesses the patient’s physical and psychological status as needed.
· Documents and reports to the appropriate staff any physical or psychological changes that may have occurred with the patient.
· Effectively communicates the patient’s status throughout the continuum of care.
· Effectively understands and can respond to the needs of the patient and family members.
· Is appropriate and empathetic to patients and families needs, providing information and discussion when appropriate while considering the specific age of the patient and their families.
· Maintains patient dignity at all times.
· Differentiates between different age groups appropriately and provides excellent care to the specific age groups accordingly and in respect to their psychological and physical needs.
· Assists with the implementation and delivery of the patient’s plan of care, and evaluate outcomes as needed.
· Makes sound nursing judgments and seeks guidance from physician or other nursing resources appropriately.
· Competently cares for all age levels demonstrating the ability to assess and provide appropriate nursing care which meets the physical, psychological, social and spiritual needs of the patient.
· Complies with hospital policies and procedures, infection control policies and departmental standards of care.
· Evaluates patients outcome and reports changes to physician appropriately.
· Serves as a role model, and resource for all other nursing and technical staff, by sharing knowledge.
· Assists with the coordination of departmental in-services and its documentation.
· Assumes other necessary duties as assigned by Director, as needed.
It is understood that this is a summary of key job functions and does not include every detail of the job that may reasonably be required.
Employee maintains competencies required for the specific patient population served.
Performs all duties in accordance with safety and other laws, rules, and regulations set forth by appropriate regulatory and government agencies and in accordance with established department and hospital policies and procedures.
May be required to perform similar or related duties as may be necessary on an emergency basis or as designated by the department manager or supervisor.
The nature of the tasks/responsibilities required of employees in this position will likely expose them to blood and body fluids. Employees will be oriented to and required to understand and follow the standard precautions for infection control. A summary list of tasks and procedures that may cause exposure to blood and body fluids is listed in the attached Physical Abilities Job Description. Also identified is the protective gear that is available.
QUALIFICATIONS:
Active Massachusetts RN License
Current CPR certification
BSN Required, MSN Preferred
3- 5 years of relevant experience in surgical services.
Some knowledge of discharge planning or case management.
Experience with Electronic Medical Record (Epic Preferred) and computer systems required, including web-based applications and some Microsoft Office applications, which may include Outlook, Word, Excel, and PowerPoint.
A Physical Abilities Job Description is a component of this Job Description.
The above statements are intended to describe the general nature and level of work being performed. This list is not to be construed, as an exhaustive list of all responsibilities, duties and skills required of personnel so classified.
Pay Range:
$33.50 – $45.09
The pay range listed for this position is the base hourly wage range the organization reasonably and in good faith expects to pay for this position at this time. Actual compensation is determined based on several factors, that may include seniority, education, training, relevant experience, relevant certifications, geography of work location, job responsibilities, or other applicable factors permissible by law. Compensation may exceed the base hourly rate depending on shift differentials, call pay, premium pay, overtime pay, and other additional pay practices, as applicable to the position and in accordance with the law.
