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Responsible for the coordination of patient care across the continuum under the auspices of a provider’s prescribed plan of care, national guidelines, and within the scope of nursing practice. Educates/provides information and support to patients in order to guide and facilitate understanding of heart failure and treatment plans prescribed by licensed practitioners and/or within scope of nursing practice. Monitors patient outcomes and participates in quality improvement activities. Contributes to and collaborates with health care team members to positively impact patient outcomes and patient experiences. Facilitates a clear line of communication between referring physicians and care providers to avoid delayed treatment planning. Facilitates Meds to Beds program and collaborates with care team provider on initiating prior authorizations on discharge medications. Completes 30-day post discharge tele-monitoring service for patients admitted with heart failure. Acts as a liaison between the inpatient and ambulatory setting by working with the outpatient clinics to establish a clinic follow up within seven days of discharge.
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