The transitional care nurse practitioner (TC-APN) is a specially trained primary coordinator of care to assure continuity throughout acute episodes of care. The TC-APN will perform an in-hospital assessment, collaborate with team members to reduce adverse events and prevent functional decline, and prepare and development a streamlined, evidence-based plan of care. The TC-APN will perform regular home visits with available, ongoing telephone support. The TC-APN will coordinate continuity of medical care between hospital and primary care providers and assist patients to first follow up visits. The TC-APN will promote active engagement of patients and family caregivers with a focus on achieving their goals. The TC-APN places an emphasis on patients early identification and response to health care risks and symptoms to achieve longer term positive outcomes and avoid adverse and untoward events that lead to readmissions. The TC-APN will collaborate with the multidisciplinary team across episodes of acute care and maintain communication between and among the patient, family caregivers, and health care providers. Oversight of day to day operations of outpatient Transitions Clinic. Collaborate with sub acute facilities within the region to provide seamless transition of care and follow patients once discharged from sub-acute facilities.
Licensed Registered Nurse in the state or New Jersey.
Certified Nurse Practitioner in the state of New Jersey.
Masters prepared in Nursing from an accredited program
Must be certified from an approved facility or completion of requirements within 90 days of hire for:
Minimum of 5 years experience in nursing in an acute care or post acute setting with two years of experience as an Advanced Practice Nurse.
Transition of Care Experience with home care and or clinic setting preferred
Demonstrated ability to establish positive, collaborative relationships with physicians, managers and hospital staff is essential.
Well-developed ability to prioritize and simultaneously manage multiple projects.