POSITION SUMMARY: The RN Transitions Nurse provides skilled nursing care to participants and serves as a participant advocate to ensure safe discharges. This position ensures efficient, safe transitions from hospitals and other care settings. It includes collaboration with the Transitions Team, Interdisciplinary Team (IDT), providers, family/caregivers, and other healthcare professionals to develop and implement a discharge plan. The RN Transitions Nurse ensures that a specific plan of care is in place, analyzes and interprets hospital records in collaboration with all parties involved, and coordinates all discharge and transportation needs. The role also includes supporting participants/families with end-of-life issues and making timely referrals.
MISSION: Improving lives, optimizing wellness, Promoting independence
Communicates with IDT, Skilled Nursing Facility (SNF), Assisted Living Facility (ALF), and hospital discharge planners, beginning at admission, to coordinate care that will be required up on discharge
Provides timely updates on hospital status to the provider and healthcare team.
Conducts hospital rounding as indicated.
Schedules care meetings with hospital discharge team for complex discharges
Make appropriate referrals to contracted facilities.
Use organization’s discharge processes while respecting participant/family values and beliefs.
Responds promptly to participant/family and hospital requests.
Supports participant/family with end-of-life issues and makes internal care team referrals.
Communicate with transitions provider and team regularly throughout the day for possible discharges from hospital.
Review and print participant Pace medication list. Obtain and implement discharge and medication orders prior to participant arriving at home
Complete weekly participant rounding at subacute facility with transitions team as needed.
Meet the participant at home at the time of discharge to perform medication reconciliation to include the ordering of new medications; communicate with the Transition team provider and pharmacy.
Perform wound care as needed; assess the need for skilled or unskilled home care services; obtains and implements orders from the provider
Ensure that all durable medical equipment (DME), oxygen, and supplies are in set up upon discharge.
Communicates effectively to the provider, IDT, nurse coordinators and to family/caregivers, including instructions regarding services, medications, and treatment.
Performs phlebotomy functions for participants when necessary. Identifies and labels specimens appropriately.
Observes, records, and reports participant’s condition and reaction to drugs and treatments to physicians/providers.
Attends daily, weekly, etc. meetings to include the Transitions Team meetings and IDT when requested
Completes fall follow up visit as related to subacute.
Other duties as requested/assigned
Graduate of an accredited Registered Nurse Program and licensed as a professional in the State of Colorado is required
Two years of health care experience in hospital, long-term or home health care setting required
One year of experience with a frail or elderly population is preferred
Must have excellent written and verbal communication skills and demonstrate the ability to interact clearly and effectively with both internal and external customers
Must be efficient with computer applications such as email, navigating the internet, using electronic timekeeping, and Electronic Health Records
Knowledge of medical equipment and instruments
Knowledge of common safety hazards and precautions to establish a safe work environment
Skill in applying and modifying the principles, methods and techniques of practical nursing to provide on-going care for participants
Ability to perform phlebotomy functions.
We strive to provide our employees with a comprehensive and affordable benefits package including Medical and Prescription Drug, Dental, Vision Care, Wellness Program, Telemedicine Program, Flexible Spending Accounts, Health Savings Account, Company Paid Basic Life and Accidental Death & Dismemberment, Company Paid Long-Term Disability, Voluntary Life Insurance, Voluntary Short-Term Disability, Accidental Injury Insurance, Critical Illness, Hospital Indemnity, 403(b) Savings Plan, Legal Shield and IDShield, Employee Assistance Program (EAP), Paid Time-Off plan. Such benefits are based on applicable state law and factors such as pay classification (full-time, part-time, or PRN/casual), job grade and length of service.
