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Registered Nurse RN Coordinator Hospital at Home
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- The RN Coordinator in collaboration with the patient/family, social workers, nurses, providers, and the interdisciplinary team, identifies patients meeting the inclusion criteria of an
- needs; development of a transition of care plans and the implementation of post-acute care plans discharge.
- The RN Coordinator will serve as an educational resource for patients/family members, providers, clinical staff at acute care and patient’s homes.
- The RN Coordinator adheres to departmental and system goals, objectives, policies and procedures, CMS CoP for discharge planning/care coordination and ensures quality patient care and regulatory compliance.
- Incorporates social determinants of health into transitions of care planning and applies risk mitigation interventions to meet the individual needs of each patient· Assists with End-of-Life conversation, Living Wills, Advance Directives, Power of Attorney, Community DNR.· Establishes and documents, based on the predicted DRG and multidisciplinary team member’s input, Anticipated Date of Transition (ADOT) and destination and updates, as needed.
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