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Inpatient Heart Failure Nurse Navigator
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$150
- This position, in conjunction with Case Management, coordinates the transition of care from one health care setting to another which includes : inpatient , Home Health Care, Skilled Nursing Facility, Rehab facilities.
- Identifies eligible inpatients using established program criteriaDelivers education to the patient and caregivers, including teach back interventionsPerforms risk assessment using standardized toolSupports non-cardiology primary providers with HF guideline directed medical therapies plan, including liaising with pharmacy
- Collaborates with other members of inpatient care team to develop discharge care planCoordinates post-discharge care to ensure seamless transitionCollaborates with pharmacist on medication reconciliationSchedules post-discharge clinic appointments Communicates with patient’s PCP and post-acute care providers regarding post-discharge care expectationsDevelops a plan for scheduled check-ins with patients and caregivers
- Helps provide QA of appropriate systems to ensure data integrity
- Recommends improvements or development of standards of practice for inpatient, post-acute, home and ambulatory care of patients
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