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Toc Np Primary Duties And Responsibilities
Provides high quality nurse practitioner coordination of care to high risk for readmission patients.
Identifies appropriate patients for care transition services, upon admission to the hospital and prior to hospital discharge, utilizing established criteria and interdisciplinary team conferences when possible.
Provides clinical support to include assessing patient transition of care needs, and communicating with multidisciplinary team for proper transition of care plans.
Works in collaboration with palliative care team to discuss end of life needs.
Works in collaboration with the Transition of Care Team to:
Serve as a guide to the patient, coaching the patient in addressing critical issues and self- management tasks rather than directly taking over and providing care.
Provide information and guidance to the patient and/or family for an effective care transition, improved self-management skills and enhanced patient-healthcare provider communication.
Evaluate aspects of each patient's condition, diagnoses, medications and support systems to formulate an individualized plan in collaboration with interdisciplinary team, which will lead to successful outcomes in medication self-management, use of a dynamic patient-centered record, appropriate primary care and specialist follow-up.
Maintains record of care transitions and makes accurate and timely documentation. TOC NPs may record appropriate progress notes on the clinical record. The sponsoring physician is not required to sign off on the TOC NP notes unless there was a new order written. A TOC NP may write Transition of Care discharge summaries for high-risk patients admitted into the TOC Program.
Rounds: A TOC NP may make rounds, unaccompanied by the sponsoring physician, to assess for transition care needs of high-risk patients admitted under the sponsoring physician's care/ group. The TOC NP also may round on high-risk patients admitted under other groups or practices and discuss needs identified with admitting team.
Makes post discharge phone calls for 30 days after discharge for patient education and coordination of care.
Forsyth Campus
No Nights
No Weekends
No Call
Performs history and physical examinations and carries out appropriate intervention/procedures as determined by the plan of care. Coordinates care of assigned patients according to Northside Hospital established Standards of Care.
Required
Master's Degree in Nursing
Please refer to the Medical Staff Guidelines for certifications and credentialing applicable to this position.