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Organization:
Team Firefly
Job Summary:
Assists in developing and meeting key Pillar outcomes and system improvement goals including financial, satisfaction, and clinical as the nursing component of the care coordination model. This position Improves outcomes by reducing all cause hospital readmissions and coordinating episodes of care among patients in a defined population or disease process. Participates in identification of appropriate patients; encourage patient and family engagement in self-care management; promote warm handovers to the next level of care by providing timely, pertinent information in a standardized way; conduct patient and family education on key elements of the patients' personal care plan by using the "teach-back" methodology and follow up phone calls; and assists the patient in navigating the healthcare system. .
Firefly is an outpatient clinical program at VUMC that provides comprehensive, multi-disciplinary care to pregnant and postpartum women with substance use disorder. Offering services including prenatal and postpartum care, social work and peer recovery support, lactation and pediatric services, collaborative mental health care, intensive outpatient programming, group therapy, and health-related social needs support including transportation, clothing, food, and diapers, Firefly seeks to support women in recovery and their families through wholistic, trauma-informed care.
Key Responsibilities:
Coordinates the evaluation process of the defined patient population. May complete and document portions of the evaluation process, collaborating with other team members to ensure completion of all required information.
Supports patient access by serving as a liaison between the referring provider's office and Vanderbilt provider.
Interacts routinely and effectively with the clinical team to develop a collaborative plan for the coordination of patient care through the defined care episode.
Leads patient care coordination meetings
establishes relationships/clinical pathways with providers/agencies to optimize care for defined patient population.
Assists in the development and dissemination of patient education materials/information
Assists with quality improvement project development and implementation.
Assists with discharge/transition planning in collaboration with the multi-disciplinary team, actively engaging outpatient care providers by sharing hospital course, concerns, pending test results, learning needs, partnership opportunities etc. Coordinates handovers including outpatient, inpatient, and regional teams.
Demonstrates reflective practice by constantly evaluating care coordination and supports the development of protocols for practice based on evidence
The responsibilities listed are a general overview of the position and additional duties may be assigned.
Technical Capabilities:
Evidence-Based Practice (Advanced): Recognizes, Implements, and evaluates practice changes based on published research. Demonstrates expertise in applying evidence-based practices to challenging and complex situations.
RN Access Patient Education (Advanced): Demonstrates uppermost levels of patient education in practical applications of a complex nature. Possesses mastery of knowledge, training, and expertise to be capable of successfully delivering…