Nurse Navigator - Community Care Center

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Every day, more than 40,000 Hartford HealthCare colleagues come to work with one thing in common : Pride in what we do, knowing every moment matters here. We invite you to become part of Connecticut's most comprehensive healthcare network.

Hartford Hospital is one of the largest and most respected teaching hospitals New England. We are a Level 1 Trauma Center that provides cutting edge treatment to its patients. This is made possible by being home to the largest robotic surgery center in the Northeast and the Center for Education, Simulation and Innovation (CESI), one of the most-advanced medical simulation training centers in the world. When hospitals cannot provide the advanced care, expertise and new treatment options their patients require, they turn to us.

The Community Care Clinic (CCC) is located at 132 Jefferson St on the third floor of the Hartford Hospital Community Health building of Hartford Hospital. CCC clinic has close to 3,000 patient visits annually with an average of 50 patients per day. The Division of Infectious Diseases provides inpatient and outpatient consultation regarding the diagnosis and management of all types of infectious diseases. The service is supported by outstanding clinical diagnostics laboratories, which provide state-of-the-art techniques for rapid diagnosis of infectious diseases. Our staff of providers, Psychiatry, fellows, Psych Residents, social worker, Nutritionist, Pharmacy Liaison, APRNs, RNs, MA / MAAs, a Case Manager and a Data Manager who provides compassionate care, excellence in teaching and investigations in clinical and laboratory research. CCC is Ryan White funded. 75% are bilingual with Spanish being their primary language. 80% of our patients have Health coverage under Medicaid. Our specialists are skilled at treating many infectious conditions, including : Conditions such as HIV infection, Hepatitis, fever of unknown origin, recurrent infections or rashes of unknown type or origin, Influenza, Opportunistic infections in patients who are immunosuppressed due to acquired or congenital immunodeficiency, transplant or other medical condition. CCC guides patients through the health system, including appropriate referrals for services to other health professionals.

Job Summary :

Functioning within the context of the framework for professional nursing practice, the Community Care Nurse Navigator is a registered nurse experienced in patient throughput, preventing transitional care gaps, and resolving issues to enhance the quality and continuity of a patient's or populations health care leading to improved health outcomes and equitable care. This role supports the HHC mission to improve the health and healing of the people and communities we serve. Under provider direction, the Community Care Nurse Navigator provides skilled nursing care to patients in a variety of clinical settings. Scope of responsibility is characterized by use of nursing process to assess, plan, intervene and evaluate human responses to actual or potential health problems utilizing appropriate practices, standards, protocols and guidelines. This position reports to a Practice Manager.

Job Responsibilities :

• Functions as a member of an interprofessional care team in an expanded nurse role to help patients transition from the acute care setting (HH ED or inpatient). The goals include reducing all-cause readmissions, and inappropriate ED utilization, improving care coordination for patients during the transitional care period, and ultimately improving care quality and access for vulnerable populations. This role will be responsible for educating the HH community at large and advocating for resources to enhance patient healthcare engagement and expand the collaboration and communication between (inpatient / ambulatory / outpatient / attending / transitional care / specialty care / primary care) providers and care teams for high risk / complex patients.
• Partners with the inpatient (i.e. acute care, IOL, STR) or ED physician and care team to proactively identify potential transitional care gaps for this patient population, and establish a safe transition plan. Key strategies include ensuring a patient / caregiver agreed upon CCC Clinic and urgent specialists scheduled appointment(s) with transportation, verifying patient has necessary DME, finalizing an achievable community medication plan, completing diagnostic workup, educating the patient on disease and symptom management, and incorporating a patient-centered home care plan.
• Performs post-hospitalization / ED transitional care strategies within 24-48h after discharge, including post-discharge phone calls, patient education, symptom management, and medication reconciliation, and collaborates with CCC clinic physician and (clinic and community) care team to minimize identified gaps in care.
• Throughout the post-inpatient / ED transitional care period, facilitates the completion of the diagnostic workup, follows up on unresulted diagnostics, collaborates with homecare, pharmacy, and DME to ensure the patient has necessary supplies / medications / resources, obtains necessary authorizations, and schedules additional consultant appointments.
• Collaborates with clinic physicians to resolve issues and to advance the treatment plan until the patient has an established primary care provider.
• In collaboration with the CCC Clinic physician, assists the patient in identifying a primary care practice for continued care and facilitates the transfer of care to that practice
• Documents all communication, transition plan, implemented strategies, and patient outcomes in EPIC.
• As a member of the CCC Clinic completes transitional care strategies and actions per CMS / Payer guidelines for Transitional Care Management or other program directives.
• Establishes a therapeutic rapport with patients and demonstrates a commitment to serve as a patient advocate.
• Demonstrates the ability to work independently as well as collaboratively as a member of the health care team in order to provide safe patient care and prompt and efficient service. The Community Care Nurse Navigator provides transitional care strategies to his / her peers / colleagues and patients based on need / coverage.
• Attends / Leads and actively participates in care team meetings to facilitate a safe transition plan or resolve a patient issue.
• Establishes evidence-based standard work and workflows. Develops and implements processes that improve the patient experience. Collects and analyzes patient and program level data identifies areas of opportunity, recommends improvements / revisions or program development, and leads / participates in the idea / plan implementation.
• Applies the nursing process as appropriate within the context of the organization's framework for professional nursing practice and following guidelines established by the team.
• Provides office-based nursing care in collaboration with provider, communicates with provider regarding patient needs, nursing assessments, and recommendations, demonstrates independent nursing actions based on assessment and problem identification.

This is a grant funded position.

Qualifications :

Bachelor's Degree required, MSN preferred

We take great care of careers.

With locations around the state, Hartford HealthCare offers exciting opportunities for career development and growth. Here, you are part of an organization on the cutting edge - helping to bring new technologies, breakthrough treatments and community education to countless men, women and children. We know that a thriving organization starts with thriving employees we provide a competitive benefits program designed to ensure work / life balance. Every moment matters. And this is your moment.

As an Equal Opportunity Employer / Affirmative Action employer, the organization will not discriminate in its employment practices due to an applicant's race, color, religion, sex, sexual orientation, gender identity, national origin, and veteran or disability status.