Inflammatory Bowel Disease Coordinator (RN) Pediatric GI Clinic #2206142
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.
Identifies which patients in the specialty care practice have ongoing care coordination needs.
Utilizes assessment skills and risk assessment tools to identify patients with actual or potential care needs that would require care coordination.
Conducts comprehensive clinical assessments that include disease-specific, age-specific, medical, behavioral, pharmacy, social and end of life needs of each patient.
Informs the patient and family regarding coordination of their care and shares this information with the healthcare team.
Works collaboratively with interdisciplinary team to develop goals and plan interventions to maximize patient outcomes.
Monitors patient compliance with plan of care.
Serves as the liaison between patients, families and physicians, clinical staff by advocating for patient and families then responding to and facilitates resolution of patient/family questions and concerns.
Train with and participate with Improved Care Now program.
Provide RN Triage support for this patient population including enrolling participants into the program, entering information into the database, reviewing data and providing plan to patients within 200 days of visit.
Discuss objectives for patient visits and plan with staff and patients via phone and updating MyChart data.
Liase with each provider regarding missed visits and share clinical data prior to each clinical visit to ensure compliance with medications, vaccinations, and health maintenance consults with other services.
Organize team meetings and manage ICN database program for patient population and participate and oversee quality improvement objectives of ICN.
Act as liaison for anyone seeking information about our program.
Engage with patient to determine compliance, and report findings to physician.
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 from the anchor hospitalization through the defined care episode.
Develops and manages the processes related to pre-admission and post-discharge care transitions; 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 to include creation of customized medication grids with input from the pharmacist/team as needed.
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 care coordinators (disease management teams), home health care nurses, cardiac rehab, skilled nursing facilities, etc.
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.
Inflammatory bowel disease (IBD) includes Crohn's disease and ulcerative colitis. These diseases affect one million Americans. Nearly one in four patients with IBD is diagnosed in childhood. IBD affects children differently than adults. That's why at Children's Hospital your child receives care from doctors and nurses specifically trained in treating IBD in children and teens. Because the condition is complex, our team includes experts in immune system health, nutrition, genetics and other disciplines. Together we are advancing our understanding of IBD through leading-edge research.
Monday - Friday 8:00 AM - 5:00 PM
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Light Work category requiring exertion up to 20 lbs. of force occasionally and uses negligible amounts of force to move objects.
Occasional: Standing: Remaining on one's feet without moving.
Occasional: Walking: Moving about on foot.
Occasional: Lifting under 35 lbs: Raising and lowering objects under 35 lbs from one level to another
Occasional: Lifting over 35 lbs: Raising and lowering objects from one level to another, includes upward pulling over 35 lbs, with help of coworkers or assistive device
Occasional: Carrying under 35 lbs: Transporting an object holding in hands, arms or shoulders, with help of coworkers or assistive device.
Occasional: Push/Pull: Exerting force to move objects away from or toward.
Occasional: Bending/Stooping: Trunk bending downward and forward by bending spine at waist requiring full use of lower extremities and back muscles
Occasional: Balancing: Maintaining body equilibrium to prevent falling when walking, standing, crouching or maneuvering self, patient and equipment simultaneously while working in large and small spaces
Occasional: Climbing: Ascending or descending stairs/ramps using feet and legs and/or hands and arms.
Occasional: Kneeling:Bending legs at knees to come to rest on knee or knees.
Occasional: Crouching/Squatting: Bending body downward and forward by bending legs and spine.Reaching above shoulders: Extending arms in any direction above shoulders.
Occasional: Reaching above shoulders: Extending arms in any direction above shoulders.
Occasional: Handling: Seizing, holding, grasping, turning or otherwise working with hand or hands.
Occasional: Bimanual Dexterity: Requiring the use of both hands.
Frequent: Sitting: Remaining in seated position
Frequent: Reaching below shoulders: Extending arms in any direction below shoulders.
Frequent: Fingering: Picking, pinching, gripping, working primarily with fingers requiring fine manipulation.
Continuous: Communication: Expressing or exchanging written/verbal/electronic information.
Continuous: Auditory: Perceiving the variances of sounds, tones and pitches and able to focus on single source of auditory information
Continuous: Vision: Clarity of near vision at 20 inches or less and far vision at 20 feet or more with depth perception, peripheral vision, color vision.
Continuous: Smell: Ability to detect and identify odors.
Occasional: Chemicals and Gasses: Medications, cleaning chemicals, oxygen, other medical gases used in work area.
Occasional: Pathogens: Risk of exposure to bloodborne pathogens and other contagious illnesses.
Vanderbilt University Medical Center is home to Vanderbilt University Hospital, The Monroe Carell Jr. Children’s Hospital at Vanderbilt, the Vanderbilt Psychiatric Hospital and the Vanderbilt Stallworth Rehabilitation Hospital. These hospitals experienced more than 61,000 inpatient admissions during fiscal year 2015. Vanderbilt’s adult and pediatric clinics treated nearly 2 million patients during this same period. Vanderbilt University Hospital and the Monroe Carell Jr. Children’s Hospital at Vanderbilt are recognized again this year by U.S. News & World Report’s Best Hospitals as among the nation’s best with 18 nationally ranked specialties. Vanderbilt University Medical Center is world renowned because of the innovation, work ethic and collegiality of its employees. From our health care advances to our compassionate care, Vanderbilt owes its accomplishments and reputation to staff and faculty who bring skill and drive and innovation to the medical center day after day. World-leading academic departments and comprehensive centers of excellence pursue scientific discoveries and transformational educational and clinical advances across the entire spectrum of health and disease.As t...he largest employer in middle Tennessee, we welcome those who are interested in ongoing development in a caring, culturally sensitive and professional atmosphere. Most of us spend so much of our lives at work, we want to be part of maintaining a workplace in which people support one another and encourage reaching for excellence. Many high-achieving employees stay at Vanderbilt because of the professional growth they experience and because of their appreciation of Vanderbilt’s benefits, public events and discussions, athletic opportunities, beautiful setting and, above all, sense of community and purpose.Vanderbilt and its employees share a set of mutual expectations that have been created with productivity, legality, fairness and safety always in mind. We believe that our investment in training and compensating employees multiplies in value when we enable individuals to deliver their best performance for the benefit of us all.