Home-Based Hospital Care RN Care Navigator

POSITION SUMMARY

 The Home-Based Hospital Care Registered Nurse (RN) Care Navigator is an integral part of the Home-Based Hospital Care clinical team, providing identification, screening, intake, care coordination, monitoring, and interventions to support acute patients in the home setting. The RN Care Navigator provides essential intake, clinical review, and care coordination to transition patients from point of entry, such as but not limited to the Emergency Department, to the Home-Based Hospital Care program. The RN Care Navigator works in collaboration with the interdisciplinary team including the Home-Based Hospital Care provider, Home-Based Hospital Care Nurse Manager, Home-Based Hospital Care RNs, Team Support Coordinator, Social Work, and ancillary services to ensure that patients receive exemplary care in their home. The RN Care Navigator plays a crucial role in managing all aspects of the patient’s acute care needs, including coordination of supporting disciplines and ancillary care services.     

Interdisciplinary conferencing is facilitated by the RN Care Navigator to ensure that all members of the care team are actively participating in the patient’s plan of care. The RN Care Navigator provides triage to the Home-Based Hospital Care patient through various methods of communication, including digital technology. This position is responsible to provide care for the Home-Based Hospital Care patient population requiring the use of advanced assessment, technical, teaching, and decision-making skills.  

The RN Care Navigator is required to work autonomously and apply critical thinking skills to each patient during the Home-Based Hospital Care episode of care. The RN Care Navigator is responsible for assessing post-acute needs and ensuring that appropriate referrals to other services are made. 

This position may require evening/weekend hours, and rotating holiday scheduling responsibilities.

• Utilizes monitoring, assessment, planning, intervention, and critical thinking skills to care for acute care patient populations in the home.
• Works with health system partners to identify, review and intake new Home-Based Hospital Care patients.
• Navigates patients and families across the continuum of the phases of care.
• Monitors and responds to biometric data per Home-Based Hospital Care protocols.
• Conducts audio/visual patient care visits as directed by the care team and/or protocol.
• Ensures all interventions in the patient’s plan of care are implemented efficiently with a patient centered approach.
• Leverages the resources and expertise of the Home-Based Hospital Care team and supplier partners to implement collaborative workflows, standards, policies, protocols, guidelines, and documentation systems to support safe, reliable, high-quality, evidence-based care with clinical protocols as the foundation.
• Adheres to the clinical protocols and is willing to obtain the necessary training to provide care within the context of providing evidence-based care.
• Promotes professional practice and a culture of safety; willingness to engage in process improvement efforts.
• Provides transitional care responsibilities, as appropriate.
• Directs the use of equipment and supplies in an efficient and cost-effective manner.
• Sets priorities of home and virtual visits, adapting to the changing needs of the Home-Based Hospital Care patient.
• Utilizes resources to problem solve new or unfamiliar patient situations.
• Works collaboratively with the interdisciplinary team to best meet the needs with the Home-Based Hospital Care patient and family.
• Documents components of the nursing process to reflect a comprehensive and integrated approach to nursing care.
• Recognizes potential problems and sets priorities according to changes in the patient’s condition.
• Informs the provider and other appropriate members of the health care team of changes in the patient’s condition and needs.
• Evaluates patient’s responses to care based on a continuing assessment and analysis of nursing intervention and alternatives for nursing care.
• Facilitates and participates in formal and informal interdisciplinary care conferences to address the needs of regarding complex patients.
• Exhibits sound nursing judgment and decision-making skills in coordinating patient care.
• Identifies and adapts teaching materials for Home-Based Hospital Care patients and caregivers to optimize the learner’s success. Involves the patient and caregiver in identification of individual requirements/perceptions of learning needs.
• Develops, implements, and evaluates individualized teaching programs using teach-back and return demonstration techniques to assess patient/caregiver level of understanding and adjust teaching and plan of care accordingly.
• Maintains an updated clinical record on each patient at all times.
• Participates in the development of program goals and evaluates progress toward goal achievement.
• Participates in committees/meetings as delegated or appointed.
• Involves the patient and caregiver in the plan of care, incorporating their cultural, spiritual, and other belief systems.
• Recognizes the importance of respecting individual patient and caregiver choices regarding care and treatment options.
• Assists leadership in identifying potential clinical practice issues and contributes to the development of specific plans to improve Home-Based Hospital Care patient outcomes.
• Demonstrates effective written communication skills.
• Demonstrates the ability to verbally communicate effectively and express ideas clearly.
• Takes the initiative to present ideas/suggestions to management.
• Communicates on a regular basis with supervisor.
• Utilizes appropriate communication lines in relaying problems, concerns, and ideas.
• Consistently follow standardized rules of language regarding spelling, punctuation, grammar, work usage, and composition.
• Composes clear, direct, and succinct written messages that effectively conveys information.
• Seeks to resolve confrontations and disagreements constructively.
• Builds good rapport with patient, caregivers, and practitioners.
• Is receptive to new ideas and views of others.
• Acts as a positive influence on others; positively impacts morale.
• Thrives in being part of a team and is self-accountable to team expectations.
• Communicates with coworkers effectively in a warm and helpful manner.
• Handles client complaints in a fair and empathetic manner.
• Gives high priority to client satisfaction.
• Anticipates customer needs.
• Maintains a courteous demeanor at all times with internal and external customers.
• Presents information clearly and effectively to both internal and external customers.
• Responds timely to changing customer and patient needs.
• Seizes opportunities to improve customer and patient satisfaction.
• Promotes Care Direct’s culture by providing quality, comprehensive services to all customers through a team approach.
• Carries out all responsibilities in accordance with Care Direct’s Mission and Service Statements.
• Demonstrates the reliability and follow through on all assigned tasks.
• Demonstrates the ability to remain calm and focused under pressure.
• Demonstrates a self-directed, mature, discipline approach to the job.
• Demonstrates the ability to cope with an ambiguous and changing environment.
• Completes expected amount of work in a timely manner.
• Completes work on schedule.
• Prioritizes responsibilities and workload appropriately.
• Demonstrates the ability to work effectively and maintain expected productivity.
• Schedules tasks to be completed based on priorities.
• Demonstrates the ability to manage multiple priorities.
• Actively takes steps to contribute to a cohesive and results-oriented team.
• Analyzes problems systematically and logically when implementing solutions.
• Shows creativity in assessing various paths to problem solving.
• Demonstrates an ongoing commitment to learning and self-improvement.
• Successfully completes initial and ongoing organizational and department education, training, and competency requirements.
• Infection Control: Understands, demonstrates, and follows organizational infection control guidelines (CDIC).
• Quality: Focuses on improving processes and champions efficiency in daily work activities.
• Safety: Promotes a culture of safety by taking accountability for individual actions, including but not limited to, promptly reporting errors or near misses via the organization’s occurrence reporting system and participating in developing improved safety processes, as appropriate. (ADM015, ADM016, OPS044, Mission Statement).
• Performs other duties as assigned.

JOB REQUIREMENTS 

Licenses:

☒ State of Wisconsin Driver’s License

☒ State of Wisconsin Professional licensure for Registered Nurse

Education:

☒ Associate degree in: Nursing required.

☒ Bachelor’s degree in: Nursing preferred.

☐ Graduate degree in:

☐ Other: 

Experience:

• Minimum of 2 years of recent experience in nursing required. 
• Experience and strong knowledge base in medical surgical clinical nursing, care coordination, or nursing triage experience preferred.
• Recent, relevant experience in home health preferred.
• Experience using EPIC and virtual health platforms preferred.
• Experience in teaching self-care skills to patients and families.

Miscellaneous:

• On call
• Current auto insurance required.
• Certifications (including but not limit to CPR/BLS)
• Knowledge regarding the impact of acute and chronic illness on the lives of patients and families in the community.
• Functions with a high degree of independence, flexibility, and autonomy.
• Collaborates with other disciplines to provide care.
• Excellent interpersonal and group process skills.