Transition of Care Registered Nurse

POSITION SUMMARY

The Transition of Care (TOC) Registered Nurse is responsible for facilitating seamless transitions for patients between healthcare settings. This role involves comprehensive patient assessments, care coordination, patient education, and strict adherence to regulatory requirements from HRSA, Arizona state regulations, and The Joint Commission, ensuring high-quality care for our underserved population.

This position is essential to Adelante’s team-based primary care medical home model of care, which supports coordinated, patient-centered, comprehensive healthcare for all. This role will perform work primarily remote and occasional travel to health centers or company facilities may be required.

 

EXPECTATIONS

Every Adelante employee will strive to maximize their performance and contribution to Adelante Healthcare and the community we serve every day.  Employees are expected to work in a manner that demonstrates a commitment to quality, patient safety, employee engagement, innovation, and the highest standards of personal integrity, professionalism, and competence.

 

• OUR CORE VALUES
• Inclusion
• Nurture
• Service
• Purposeful
• Integrity
• Resilient
• Engaged

Qualifications

 

ESSENTIAL SKILLS AND EXPERIENCE

• Graduation from an accredited nursing program
• Licensed with the AZ State Board of Nursing
• License to be in good standing
• Demonstrated application of Nursing Planning (Assessment, Nursing Diagnosis, Goals/Outcomes, Implementation, and Evaluation)
• Demonstrated understanding of clinical methods and techniques used in record-keeping systems
• Demonstrated ability in implementing the principles and practices of supervision
• Good working knowledge of Microsoft Office applications, including Outlook, Word, and Excel 
• Must be able to write analytic reports integrating multiple data elements and perspectives 
• Must be familiar with Adelante healthcare mission, vision, and core values and use them during patient care and collaboration with non-clinical and clinical teams
• Must be able to maintain confidentiality, privacy, and security of protected information 
• Must possess excellent verbal and written communication skills, with the ability to communicate effectively with internal and external customers 
• Travel to all health centers is required as needed
• Advanced computer efficiency in the Microsoft Office suite (Word, Excel, PowerPoint, Outlook) and experience in the Patient Management System
• Meet the organization's immunization requirement
• Valid Arizona driver’s license
• Two (2) to five (5) years of experience in a clinical setting
• Certification to perform cardiopulmonary Resuscitation for the Health Care Professional (CPR) and AED through courses that follow the guidelines from the American Heart Association and the Red Cross (cognitive and skills evaluations)
• Valid Level One Fingerprint Clearance Card issued by the Arizona Department of Public Safety for all specialty behavioral health locations
• Participation in Community Events as required

 

POSITION RESPONSIBILITIES/ESSENTIAL

 

Patient Care Responsibilities

• Conduct comprehensive initial and ongoing assessments of patients' medical and behavioral health needs during transitions from inpatient to outpatient care or between service providers.
• Support transition of care (TOC) through coordination of continuity of patient care with internal and external healthcare organizations and facilities, such as referrals to outside specialties and ongoing two-way communication between providers and care teams.
• Engage patients actively in their care processes, promoting self-management, health literacy, and wellness strategies.
• Perform medication reconciliation during transitions, identifying discrepancies and ensuring a complete review of medication lists.
• Collaborate with healthcare providers to recommend appropriate pharmacological therapies based on clinical assessments and evidence-based practice.
• Coordinate outreach efforts to high-risk patients and hospital discharge and admissions.
• Educate patients about their medications, including indications, adherences, and potential side effects.
• Review and act on care team tasks and inbox messages.
• Identify barriers to care and social determinates of health.
• Perform medication refills, prior authorizations, and referrals.
• Facilitate patient care based upon approved standing orders and protocols.

 

Clinical Collaboration

 

• Actively support the referral process in accordance with AHC policies and procedure and standing orders, ensuring timely and efficient patient transitions post hospital discharge.
• Partner with patients to develop Self-Management Goals (SMGs) framed within the SMART criteria (Specific, Measurable, Attainable, Realistic, Time-bound). This approach fosters patient-centered care by empowering individuals to take an active role in their health management.
• Utilize critical thinking skills to troubleshoot and problem-solve during complex situations, ensuring the appropriate and effective solutions are implemented to address patient needs.
• Work collaboratively with an interdisciplinary team, including medical and behavioral health providers, case managers, integrated health staff and community health workers, to enhance care coordination and improve patient outcomes.
• Participate in regular case reviews and interdisciplinary team meetings to discuss complex patient needs and strategize on streamlined care transitions.
• Reviews and interprets laboratory results, providing critical insights and recommendations to the clinical team to guide decision making and tailored interventions for each patient’s care post hospitalization.
• Work collaboratively with the Transition of Care Program Manager, clinical team on data collection, health outcomes reporting, and clinical audits. Participate actively in programmatic evaluations that assess effectiveness and drive continuous improvement in patient care initiatives.

 

Quality Improvement, Care Coordination and Regulatory Compliance

• Collaborate with the interdisciplinary team to improve the Uniform Data
• Contribute to quality improvement initiatives to enhance the transitions of care process, emphasizing patient safety, satisfaction, and regulatory compliance.
• Collect and analyze data related to patient outcomes and participate in developing strategies for quality enhancements in line with HRSA and Joint Commission standards.
• Maintain accurate and timely documentation of patient assessments, individualized care plans, and progress notes within electronic health records (EHR), adhering to legal and organizational standards.
• Thoroughly document all patient interactions, care recommendations, and follow-up plans to meet HRSA, state, and Joint Commission requirements
• Ensure compliance with the Health Resources and Services Administration (HRSA) guidelines, Arizona state regulations, and The Joint Commission standards.
• Stay updated on relevant policies impacting medical and behavioral health care delivery and documentation processes specific to FQHCs.

Leadership and Accountability

• Provide leadership for collaboration and coordination of services, which includes defining the appropriate skill mix and delegation of tasks among licensed and unlicensed healthcare staff.
• RNs are fully accountable for their practice, maintaining high standards of care and ethical responsibility in all interactions and clinical decisions.

Patient Education and Reporting

• Foster and maintain relationships with external healthcare organizations and facilities to identify and secure additional resources that support patient care initiatives and enhance service delivery.
• Conduct through patient assessments to develop individualized education plans tailored to meet specific patient needs and learning styles.
• Provide education and emotional support to patients and their families regarding care plans, treatment options, and available community resources through Adelante health Care.
• Empower patients by equipping them with the knowledge necessary to engage effectively in their care journey.

 

Administrative Responsibilities

 

• Obtain medical records, labs & diagnostics results as needed.
• Align role and responsibilities with Adelante Healthcare's mission, vision, core values policies, and procedures
• Ensure proper and complete documentation using approved templates in the electronic health record.
• Participate in team meetings as needed.

Skills and Competencies

• Apply critical thinking and organizational skills in all tasks related to TOC and the organization’s standards.