(RN) Transitional Care Nurse Coordinator - Congestive Heart Failure Clinic

Registered Nurse - RN - Congestive Heart Failure - Transitional Care Nurse Coordinator

Work where every moment matters.
Every day, more than 40,000 Hartford HealthCare colleagues come to work with one thing in common: Pride in what we do, knowing every moment matters here. We invite you to become part of Connecticut’s most comprehensive healthcare network.

Hartford Hospital is one of the largest and most respected teaching hospitals as well as a Level I trauma center. Hartford Hospital is on the cutting edge of technology & medical care and is home to the Center for Education, Simulation and Innovation (CESI), one of the most-advanced medical simulation training centers in the world. Housing the Northeast’s largest robotic surgery center, committed to becoming the best in the country for patient safety and is pursuing that goal by taking innovative action and creating a culture of safety at every level within the organization.

The Hartford HealthCare Heart & Vascular Institute brings together cardiac care specialists – increasing collaboration and care coordination – all under one roof. Our system of care includes a truly integrated team with the most talented, experienced, and compassionate caregivers and physicians, backed by the latest cutting-edge technology.
The award-winning Heart & Vascular Institute is a national leader in advancing cardiac care, offering heart disease prevention, treatment, surgery and research. We received “top performer” recognition by The Joint Commission for performance on evidence-based care processes for the treatment of heart attack, and were recognized by the American Heart Association and American Stroke Association as a Get with the Guidelines® - Stroke GOLD PLUS Achievement Award winner in 2016.

Job Summary
Heart Failure Transitional Care Nurse Coordinators participates in an expanded nurse role as an integral member of the Heart Failure Team. They are at the forefront of the Heart Failure Disease Management Program and work in a collaborative environment with strong patient-centered interdisciplinary teams, focused on a patient-centered care model in a richly diverse work space. The nurse coordinator must possess our institutional values of integrity, kindness, safety, nurse excellence, leadership, professionalism, and loyalty while providing high quality safe care. Under the direction and general supervision of the Heart Failure Program Manager, the registered nurse coordinator uses high-level critical thinking skills and expertise in the safe administration of various heart failure intravenous medications aimed at decongestion while also balancing and providing the framework of a robust comprehensive advanced heart failure management program. The Heart Failure Transitional Care Nurse Coordinator utilizes evidence based practices in accordance with the State Nurse Practice Act, policies and procedures of the hospital and as directed by the medical staff. With a goal of reducing readmissions and improving quality of life for patients, coordinators use expert knowledge and the nursing process to develop a plan of care which includes standards of practice to meet the physical, emotional, spiritual, cultural, and educational needs of the patient and family. The coordinator provides specialty and individualized care, implementing interventions including heart failure education, medication education, dietary education and on-going counseling, promotion of self-care, and adherence to a therapy plan.

Key Areas of Responsibility
• Independently obtains and performs assessments while safely triaging and guiding a patient’s clinical course. Presents patient history and clinical presentation to a Provider. Establishes, implements, and evaluates an individualized plan of care with timely and appropriate clinical advice and interventions.
• Perform extensive review of medications and eliminates inadvertent inconsistencies across transitions in care. Communicates effectively with Providers to validate and verify medications and ensure medication safety and improved effective medication reconciliation and follow-up care.
• Facilitates coordination of care across the continuum and collaborates with Advanced Practice Providers and Physicians to utilize therapy protocols. Performs IV and medication therapy, assessment, and evaluation of the patient
• Participates in the overall program growth, referral base, outreach, protocol establishment and re-evaluation
• Participates in research and present programmatic milestones and accomplishments in various venues
• Leads heart failure support groups, educational sessions, and develops Heart Failure newsletters, and other activities/ materials as needed.
• Coordinates the Heart Failure patient experience throughout the Hartford Healthcare continuum based on the individual needs of the patient.