Assessment
Reviews baseline data related to patient: medical, psychosocial, spiritual, financial, and other patient needs. (This includes review of pathology and test results.)
Assesses educational needs of patient/ family related to disease, treatment, side effect management, resources, etc.
Conducts ongoing assessments of patient / family at specific identified time periods (e.g., diagnosis, beginning and end of treatment, recurrence, etc.)
Assesses barriers to care for the patient / family, including health disparities, cognitive, psychosocial, financial, transportation, childcare, etc.
Assesses community resources that are appropriate for the patient / family.
Diagnosis and Planning –
Collaborates with multidisciplinary team to create and/or update patient’s plan of care, which is feasible and understandable to the patient / family.
Assists the patient and family in the treatment planning process:
(1) provides education on resources available to support the patient/family during and after treatment
(2) helps the patient identify and implement short and long term goals.
Communicates the plan of care with the multidisciplinary team.
Implementation / Coordination of Care –
Provides Services:
- Provides services for a select patient case load.
- Serves as a clinical resource for patients / families at specific points of access (e.g., Imaging, clinics, hospital, palliative care, etc.)
- Maintains communication with patient / family members at defined timeframes in patient’s disease trajectory (e.g., screening, diagnosis, treatment, survivorship / palliative care).
- Serves as a liaison with the multidisciplinary team members and various departments / specialties (both inside and outside of TCH) in order to integrate pertinent patient information for the seamless continuum of care.
- Collaborates with the health care team to communicate with the patient and family regarding referral, treatment, symptom management and follow-up (survivorship or palliative care).
- Uses technologies (e.g., EMR, My Chart, etc.) to enhance communication among patients and health care providers.
- Serves as a professional resource to the team members in the Service Line regarding current trends in care, disease management, side effect management, and community resources.
- Participates regularly in onsite multidisciplinary patient conferences, consultations, and/or committee meetings (e.g., Tumor Board, etc.)
- Promotes evidenced based practice related to area of specialization and applies findings to policies and procedures.
- Plans, implements, and evaluates educational and/or supportive programs for patients / families, staff, and the community on appropriate topics.
- Participates in Community Activities, such as providing education at Health Fairs, church groups, etc.
Remove Barriers:
- Assists patients to overcome barriers to care: financial, transportation, childcare
- Refers patients to supportive services, including financial counselors, dietitians, social workers, and community agencies
- Reaches out to underserved or rural populations.
Evaluation / Outcomes related to Quality Measurements
Identify outcomes related to quality measurements for the Patient Navigation program, such as patient / family/ physician satisfaction, accuracy, efficiency, timeliness, etc..
Create and utilize tools to measure the outcomes for the Patient Navigation program.
Review outcome results to ensure that care is delivered to patients in accordance with national professional organization standards, guidelines, and benchmarks.
Documentation –
- Documents recommendations made at multidisciplinary conferences, and distributes to appropriate multidisciplinary team members.
- Documents patient / family education in the patient’s electronic medical record. - Develop and utilize documentation tools to track encounters (e.g., follow up mailings, emails, phone calls, interactions, etc.) of Patient Navigator with patients / families.
Leadership –
- Assists the Service Line Leadership Team with planning, implementing, and evaluating outcome studies, projects, and research related to the Patient Navigation Program.
- Collaborate with the Patient Navigation team in developing processes, documentation forms, patient educational materials, and patient / family education and support programs for the Patient Navigation Program.
- Demonstrates leadership skills such as the ability to motivate, educate, delegate, and mentor peers and other members of the healthcare team while effectively managing the care of patients and family members.
- Report outcomes of Patient Navigation program to appropriate leaders and team members.
Professional Development –
- Identifies own learning needs.
- Assumes responsibility and accountability for own professional growth and development.
- Attends educational offerings that promote professional development.
- Participates in at least 75% of multidisciplinary team conferences.
- Contributes to the professional development of peers, colleagues and others.
1) Supports self and peers in professional growth and development utilizing resources and opportunities within and outside of The Christ Hospital. Acts as a resource, educator and preceptor for staff and nursing students.
2) Completes all educational, requirements to maintain competency related to specific population of patient and/or regulatory agencies (Healthstream education 100% on-time completion and attendance for annual education day). Submits required tests and paperwork in a timely manner without management interventions.
3) Participate in self and peer review activities to include the positive recognition of peers and staff on a regular basis.
4) Prepares for certification related to Patient Navigation and/ or specific patient population, when eligible.
5) Participates in chosen / relevant professional organizations, conferences and research, as appropriate.
6) Evaluates nurse-sensitive outcomes and participates in performance improvement initiatives.
7) Participation in research activities is encouraged.
Productivity –
Understands factors related to cost and effective outcomes when planning and implementing patient care.
1) Prioritizes and completes work assignments within allotted time.
2) Initiates care in a timely manner, manages workload effectively.
3) Understands and maintains awareness of fiscal responsibility by utilizing staff, time, equipment, and supplies appropriately.
KNOWLEDGE & SKILLS:
EDUCATION: Graduate of an accredited school of nursing. BSN strongly preferred, equivalent combination of Nursing education and RN experience as determined by leadership may be considered. Additional training in Nurse Navigation, Advance Practice, or Nurse Practitioner preferred.
YEARS OF EXPERIENCE: At least 2 years of relevant specialty nursing experience is required (e.g., oncology, surgery, orthopedics, etc.)
REQUIRED SKILLS AND KNOWLEDGE:
The RN will:
• demonstrate the knowledge, abilities, and skills to provide age and culturally specific patient care and education;
• demonstrate effective verbal and written communication skills and interpersonal skills with peers, physicians, patients, families, and team members;
• use appropriate channels of communication;
• maintain patient / family confidentiality (HIPPA);
• demonstrate ability to prioritize and perform multiple tasks;
• be highly self-motivated, flexible and creative, with strong leadership and presentation skills;
• demonstrate critical thinking with problem resolution;
• maintain competence and demonstrate evidence of continuing professional growth;
• demonstrate the ability to accept and implement change;
• demonstrate the ability to work and function independently in a variety of settings, including culturally diverse settings.
LICENSES & CERTIFICATIONS:
The RN holds a current licensure to practice nursing in Ohio, Membership in professional organizations is desirable, BLS certification is required prior to patient contact, Certification in area of clinical specialty is preferred on hire, but is required within one year of becoming eligible for certification.
