• Transitional Care Nurse RN Home Care Baystate VNA Full Time

    Company: Baystate Health

    Location: Massachusetts

    Date Posted: May 06, 2013

    The Transitional Care Nurse (TCN) is an expert in providing comprehensive care to chronically ill patients as they transition from hospital to home. The TCN uses evidence based care coordination approach and provides services designed to streamline the patient plan of care and interrupt patterns of frequent acute hospitalization or emergency department use. The TCN collaborates with the patient, caregiver, the patient's physician and other health team members to facilitate an effective transition that increases the patients and caregivers ability to manage their care at home. Collaborates with inpatient team, attends care meetings and discharge planning meetings. Communicates with home health team, PCP and appropriate specialists about the patient's goals and plan. The Transitional Nurse...

    from Baystate Health