Strength Through Diversity
Ground breaking science. Advancing medicine. Healing made personal.
Roles & Responsibilities:
The Registered Nurse functioning within the Transition of Care Center Department will conduct post-discharge telephone calls on patients within 24-72 hours discharged across MSHS for the purpose of telephonic assessment of each patient', health status symptom management, medications, appointments, home services and or equipment, and plan for addressing potential problems related to diagnosis, discharge or discharge plan.
Essential Duties and Responsibilities
1. The Registered Nurse functioning within the ToCC department will complete outbound post-discharge telephone calls for the purpose of telephonic assessment of each patient’s current health status and to ensure that discharged patient receives the necessary services and resources within prescribed discharge treatment plan.
a. Identify gaps or barriers in prescribed discharge treatment plans
b. Provide patient education to assist with self-management of disease
c. Make referrals to outside sources as necessary, advised or eligible
d. Coordinate services as needed (home health, DME, etc.)
e. Identify need for and administer further education on disease processes
f. Provide patient encouragement and education on healthy lifestyle choices
g. Document and track findings as per ToCC protocol & platform specifications
2. Conducts actions to prepare for a successful telephonic assessment including, but not limited to:
a. Understand patient’s clinical course through thorough clinical review of information and documentation during recent hospital stay, including but not limited to:
i. Health history
ii. Medication Reconciliation
iii. Discharge Plan
iv. Medications Prescribed
v. Diagnosis and Condition at Discharge
vi. Any Discharge Instructions provided to the patient at moment of discharge
vii. Relevant tests and lab work (pending and complete) relevant to the transition period or/or risk for re-hospitalization.
b. Review any post-acute services such as home care, DME, scheduled tests or scheduled appointments.
c. Review any special instructions communicated by the discharging in-patient nurse or other member of the care team, including but not limited to discharge telephone call specifications (whom to call, when to call, and preferred telephone number)
d. Review preferred language, presence of disabilities, and cultural preferences and arrange for necessary services to assure call is patient-centric and accessible
3. Conducts actions for the completion of a successful telephonic assessment call including, but not limited to:
a. Assess health status
b. Assess patient understanding of medical conditions, discharge instructions and self-management of disease
c. Reconcile medications to assure accuracy and safety of medications in the home and ascertain patient understanding of process for, and purpose of, adhering to prescribed medication regimen
d. Clarify and confirm prescribed discharge treatment plan appointments, test & procedures
e. Determine suitability, accessibility, and status of post-discharge home services & equipment, ensure smooth service transition and equipment installation in home, and coordinate additional services, as necessary
f. Review plan for addressing potential problems related to diagnosis, discharge or discharge plan
g. Address all identified issues and escalate or communicate to physician/care team as necessary
h. Utilize “Teach-Back” method to confirm patients/care givers understand communicated information
i. Utilize Interpreter Services as necessary
4. Conducts appropriate post-call actions including, but not limited to:
a. Appropriately identify all post-call interventions including communication, escalation, referral to additional services, any additional follow-up calls to or on behalf of patients
b. Communicates necessary needs and interventions to providers and members of the care team
c. Delegates appropriate tasks and administrative needs to assigned Patient Navigators
d. Documents call, actions taken, and completes transfer of care report to Coach colleague as assigned/needed
5. Ensures that the patient’s progress, or lack of progress, is reflected in progress notes and in the revised care plans
6. Discharge planning consistent with the patient’s status and reflects inter-departmental and inter-agency communication
7. Communicates information to the patient based on the patient’s level of awareness and readiness to learn
8. Patient care assignments reflecting an awareness of patient needs and skill level of personnel
9. Demonstrates the knowledge and skills necessary to provide care, based on physical, psychosocial, educational, safety, and related criteria, appropriate to the age of the patients served in assigned area
10. Acts as liaison between providers, hospitals and program staff, serving as a patient advocate through recommendations on care plan alternatives or improvements
11. Communicates condition of patients and unit requiring additional intervention to the leadership person in the relevant discipline
12. Participates in the development of other staff members
13. Communicates with peers in an appraisal of practice as it relates to self and other nursing personnel
14. Periodically handles escalated clinical issues from the non-clinical staff
15. Reflects a collaborative effort in meeting the needs of the patient and unit through communication and nursing actions
16. Provides direction, assistance and support
17. Assumes accountability and responsibility for completion and quality of assigned tasks
18. Identifies and communicates to immediate supervisor the need for further staff education
19. Reflects awareness of authorities and responsibilities of nursing management levels by communication with nursing leadership
20. Seeks and utilizes nursing leaders as role models and resource persons
21. Reflects collaborative effort in meeting patient and unit needs by communication with other disciplines
22. Demonstrates a professional, courteous, and respectful attitude in dealing with patients, families and significant others
23. Displays courtesy, tact and patience during interactions with all members of the hospital staff and extended community
24. Utilizes “Teach-Back” method to confirm patients/care givers understand communicated information
25. Utilizes interpreter services as necessary
26. Participates in departmental quality assurance and performance improvement initiatives
Bachelor of Science with a major in nursing
preferred. Associate degree in nursing is considered only with relevant
experience if approved by Chief Nursing Officer or designee.
Must have relevant clinical competence in area of nursing practice; new graduates possess current knowledge of the nursing process and its application.
Evidence of ability to maintain interpersonal relationships, communicate appropriately to others, work effectively to solve problems and confronts issues appropriately.
Demonstrates a strong commitment to furthering institutional goals through interdisciplinary teamwork, effective communication, and the ability to think creatively.
Ability to read, write, understand and speak English in a clear and concise manner.
Visual, aural, and cognitive ability to assess patient status. Physical and mental health necessary to care for acutely ill patients with a broad variety of diagnoses and behaviors on a daily basis.
Strength Through Diversity
The Mount Sinai Health System believes that diversity is a driver for excellence. We share a common devotion to delivering exceptional patient care. Yet we’re as diverse as the city we call home- culturally, ethically, in outlook and lifestyle. When you join us, you become a part of Mount Sinai’s unrivaled record of achievement, education and advancement as we revolutionize medicine together.
We work hard to acquire and retain the best people, and to create a welcoming, nurturing work environment where you can develop professionally. We share the belief that all employees, regardless of job title or expertise, can make an impact on quality patient care.
Explore more about this opportunity and how you can help us write a new chapter in our story!
Who We Are
Over 38,000 employees strong, the mission of the Mount Sinai Health System is to provide compassionate patient care with seamless coordination and to advance medicine through unrivaled education, research, and outreach in the many diverse communities we serve.
Formed in September 2013, The Mount Sinai Health System combines the excellence of the Icahn School of Medicine at Mount Sinai with seven premier hospital campuses, including Mount Sinai Beth Israel, Mount Sinai Beth Israel Brooklyn, The Mount Sinai Hospital, Mount Sinai Queens, Mount Sinai West (formerly Mount Sinai Roosevelt), Mount Sinai St. Luke’s, and New York Eye and Ear Infirmary of Mount Sinai.
The Mount Sinai Health System is an equal opportunity employer. We promote recognition and respect for individual and cultural differences, and we work to make our employees feel valued and appreciated, whatever their race, gender, background, or sexual orientation.