TRAVEL 75% - locally
Coordinates the care of patients to ensure a planned transition into Renal Replacement Therapy (RRT). Facilitates improving the management of co-morbid diseases in renal patients as they start dialysis and coordinates processes to prevent and reduce hospitalizations by improving patient outcomes. Provides oversight and leadership during the patient transition period. Collaborates with local management, physicians and facility staff to develop a structured program of prompt medical and educational strategies in incident CHD patients. Ensure that all pertinent patients receive 3 months of intervention in management of anemia, dosage of dialysis, nutrition, and dialysis access and a comprehensive education program.
ESSENTIAL DUTIES AND RESPONSIBILITIES
The following duties and responsibilities generally reflect the expectations of this position but are not intended to be all inclusive. Other duties may be assigned.
- The Quality Care Coordinator will assist patients with the transition into the dialysis clinic within the first 90 days of their dialysis care and when patients are admitted to the hospital.
- Functions as an orientation contact for CKD patients in stage 4+ who are interested in future dialysis with USRC.
- Help patients manage health issues and help identify risk factors.
- Track outcomes and data comparison.
- Medication reconciliation and management.
- Communicate with physician when patients are admitted to the hospital.
- Follow patients admitted to the hospital and prepare for transition back into the outpatient setting.
- Visit patient in home or in clinic within 48 hours of discharge from hospital.
- Function as case manager for incidents involving in-center HD patients for first 3 months of dialysis.
- Educate incident in-center HD patient and family to allow them to understand ESRD, co-morbidities, hemodialysis, access care, medications, lab values, fluid management, lifestyle changes, self- care skills and modality options aligned with patient centered life and care goals.
- Evaluate patient's vascular access. Coordinate with Vascular surgeon to have vein mapping and permanent access evaluation within the first month of dialysis for those with a catheter. Reinforce catheter care, signs/symptoms of bloodstream infection. Post op permanent access education and monitoring: AVF maturation, AVG healing. Facilitate timely catheter removal.
- Evaluate patient's weight gain between treatment, volume status, blood pressure, individualized maximal rate of safe fluid removal, lab values, diabetic care and medication.
- Utilize motivational interviewing to help create and implement patient's individualized multidisciplinary care plan.
- Help patient meet treatment goals, to include monitoring home blood pressure and parameters for self adjustment of blood pressure prescription if possible, based on home blood pressure results, with MD approval and input.
- Follow up regularly on treatment goals and when deemed appropriate, collaborate with dialysis staff, MD and/or Nurse Practitioner to adjust treatment plan to achieve target values
- Document all activities in electronic medical record.
- Participate in facilities QAPI program as needed.
- Participate with corporate education and QAPI program as needed.
- Communicate with various corporate departments as needed.
- Ensure compliance with policies and procedures in accordance with state and federal regulations relating to education and services (CMS, HIPAA, OSHA, AMMI or other governing agencies).
Other duties and responsibilities as assigned
- Work overtime with little or no notice as needed.
- See patients evenings and weekends as needed.
- Assist in the training of new staff members as requested.
- Attend staff meetings, phone conferences, quality improvement meetings, educational activities and training as needed
- Know, understand and follow employee guidelines, employment policies and department or company procedures
- Consistent, regular, punctual attendance as scheduled is an essential responsibility of this position
- Ability to lift minimum of 5 lbs. to a maximum of 20 lbs. unassisted and able to perform repetitive standing, sitting, stooping, walking, stretching, reaching and use full range of body motions including continuous keyboarding and telephone use. Vision adequate to perform essential duties and responsibilities of the position. Ability to pass color vision test if applicable.
- Travel between clinics and within assigned area as needed.
This position has no direct reports.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
EDUCATION and/or EXPERIENCE
- Degree in nursing from an accredited school
- Must have at least two (2) years of dialysis experience
- Knowledge of and/or willingness to learn all renal replacement modalities (transplant, home therapies, in-center therapy, palliative care) without bias.
- Basic computer skills and proficiency required in MS Outlook; proficiency in all required computer systems of the company including Pearl, etc. within 90 days of hire.
CERTIFICATES, LICENSES, REGISTRATIONS
- Current applicable license in state of practice required (RN)
- Current CPR certification
ESSENTIAL BEHAVIOR, SKILLS, ATTITUDE
o Demonstrated interpersonal, collaborative and relationship-building skills; ability to interact positively with fellow employees at various levels across the company
o Demonstrated ability to communicate effectively to a diverse audience with varying levels of understanding related to ESRD
Ability to add, subtract, multiply, and divide in all units of measure, including metric weight and volume measurements, using whole numbers, common fractions, and decimals. Ability to calculate drug doses, both oral and intravenous, and IV rates.
- Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists.
- Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.
- Offer support in the event of patient emergency and assist in managing situation until patient is stable and/or transported to an emergency facility.
- Coordinate with clinic management to assist patient in modifying schedule to ensure appointments are on time.
The physical requirements can vary. In general, the position requires the following activities:
- Ability to lift minimum of 5 lbs. to a maximum of 20 lbs. unassisted
- Able to perform repetitive standing, sitting, stooping, walking, stretching, reaching and use full range of body motions including continuous keyboarding and telephone use.
- Hearing must be adequate to hear machine alarms and interact in person clearly and efficiently and be able to report to the primary care giver for assistance
- Vision adequate to perform essential duties and responsibilities of the position.
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Job required tasks routinely involve a potential for mucous membrane or skin contact with blood, body fluids, tissues or potential spills or splashes. Use of appropriate personal protective equipment is required for every healthcare provider in these positions. Normal hazards associated with business travel.