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Acute Care Nurse will be following the patient throughout the continuum of care when patient discharges to a Skilled Nursing Facility (SNF) or Long-Term Care (LTC) to provide weekly updates on discharge and ensure that upon discharge patients is connect back to the care of the primary care provider.
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Acute Care Nurse will provide warm hand off to the Community Care Nurse when patient is discharged to home and/or from post-acute care facilities. The Acute Care Nurse role also involves establishing relationships with patients’ families and care givers, primary care physicians, hospitalist, specialists, social workers, other case managers and nurses, acute and post-acute facilities, home health care companies, and health plans.
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In markets as appropriate, when patient in SNF, in conjunction with the post-acute physician, coordinates the transition to a lower level of care as soon as appropriate using a preferred provider if further services are needed.
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The acute care nurse will anticipate the need for post-acute and/or long-Term care, from day one (1) of hospital stay, providing support to all parties involved. The Acute Care Nurse is responsible for achieving positive patient outcomes, managing quality of care across the continuum of care with efficient allocation of healthcare resources.
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