Location: Lebanon,NH, USA
OverviewWorks as a key member of the DH Care Management team, and in partnership with non-DH hospitals, by rounding on DH patients at non-system hospitals to improve the transition of care from hospital to the post-acute setting. Partners with internal and external teams, patients, and families to understand and ameliorate barriers to successful discharge, ensure comprehensive follow up care is in place, streamline workflows and communications, improve patient outcomes, and reduce readmissionsResponsibilities* Rounds, in person, on DH attributed patients who are admitted to select non-system hospitals.* Performs a focused nursing assessment to include health and disease understanding and management, functional status, cognitive/mental status, nutritional status, available support system, cultural requirements, spiritual needs, identify psycho-social-financial concerns and assesses environmental limits and Works with Care Management team, PCP, specialists, and inpatient team to ameliorate identified barriers to a successful transition to post-acute setting.* Actively works with PNO Director of Care Management, hospital leadership, and DH Medical Directors in developing, assessing, and adjusting workflows for this new role.* Act at the main point of contact for the non-system hospital staff for designated hospitals. This may include calls from inpatient physicians / clinicians regarding DH patients who are admitted.* Joins inpatient hospital rounds for DH patients as able* As a guest of the non-system hospitals, and in representing DH, ensures the highest level of collaboration, communication, and professionalism.* Schedules a post-discharge visit with DH PCP and / or specialists with the patient/family prior to discharge to ensure appointment set up, and communicates to teams. Sets patient up with Zoom to facilitate a post-discharge Care Manager call via video.* Participates in the development of disease management strategies for the PNO and identifies appropriate measures for the evaluation of Determines potential focus for groups of patients using available data and tools.* Contributes to the development and maintenance of a care delivery system which is patient/family centered and promotes effective resource* Assists in collecting and evaluating clinical and financial data/outcomes including patient satisfaction, health and functional status, resource utilization, cost and role effectiveness. Identifies and recommends opportunities for improvement in the Leads or participates in quality improvement projects for the practice, especially related to the management of patients with chronic illness. Participates in case conferencing in conjunction with peers and the clinical team. Assists in the development of department annual goals and the identification of outcomes for continuous quality improvement.* Assists with coordination of services through the continuum of care that balances the delivery of quality care with the cost effective utilization of Executes activities and/ or interventions that will accomplish the case management plans.* Acts as a patient advocate utilizing the essential activities of case management: assessment, planning, implementation, coordination, monitoring and evaluation* Performs other duties as required or assigned.Qualifications* Graduate from an accredited Nursing Program required.* Bachelor of Science Degree in Nursing* Previous inpatient nursing experience* Excellent assessment, communication, interpersonal, and organizational/time management skills.* Demonstrated ability to work well as a member of a team and respond calmly and effectively in a fast paced environment.* Excellent verbal and written communication skills.* Sound decision making, judgment, time management and negotiating skills.* Familiarity with electronic medical records, and computer applications including MS Word and Excel.* Must demonstrate passion for care of patients with chronic disease.* Sound decision making, judgment, and negotiating skills.* Knowledge of methods to educate and counsel patients, assess their readiness for changing health behaviors.Required Licensure/Certifications- Licensed Registered Nurse with New Hampshire eligibility.- Basic Life Support (BLS) Certificate required upon hire* Remote:Hybrid Remote;* Area of Interest:Nursing;* FTE/Hours per pay period:1.00 - 1.00 - 40 hrs/week;* Shift:Day;* Job ID:27300;Dartmouth Health is an Affirmative Action and Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, or protected veteran status and will not be discriminated against on the basis of disability.Dartmouth Hitchcock Medical Center and Dartmouth Hitchcock Clinics comply with applicable Federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability, or sex. We do not exclude or treat people differently because of race, color, national origin, age, disability, or sex.