RN, Heart Failure Program Coordinator

Oregon Health & Science University; Portland (OR); On-site; USD 90,000 - 120,000; Full time

Job summary

Oregon Health & Science University in Portland is seeking a Heart Failure Nurse Coordinator to oversee comprehensive specialized care for adults with advanced heart failure in both inpatient and outpatient settings.

The role partners with the health care team to ensure evidence-based practice, supports education across facilities, and drives quality improvement through care coordination, discharge planning, and registry data interpretation.

Responsibilities

• Oversee inpatient rounding and education for heart failure patients (high-risk cohort).
• Coordinate transitions of care between inpatient and outpatient settings.
• Provide program education within facilities and collaborate with care teams and leadership.

Job description

Department Overview

The Heart Failure Nurse Coordinator is responsible for coordinating the comprehensive specialized care for patients within our Advanced Heart Failure Program, both in the inpatient and the outpatient setting. The coordinator collaborates with the health care team and provides leadership in achieving standards of care, including on-going quality and evidence-based practice to ensure process efficiencies.

This role also provides formal and informal program education within facilities as is relevant, and collaborates with facility administration, medical directors, nursing staff and community partners in order to assure process improvement for the care of the advanced heart failure patients. Through knowledge and experience, the Heart Failure Nurse Coordinator should have the skill set to coordinate and oversee the patient care of this high-risk patient population throughout the continuum and can organize and interpret trends in registry data points and focus on continually improving patient outcomes. The Heart Failure Nurse Coordinator can support professional knowledge and healthcare management through effective interactions and communications with clinicians, health care administrators, community agencies and other professionals.

Department Overview

The Heart Failure Nurse Coordinator is responsible for coordinating the comprehensive specialized care for patients within our Advanced Heart Failure Program, both in the inpatient and the outpatient setting. The coordinator collaborates with the health care team and provides leadership in achieving standards of care, including on-going quality and evidence-based practice to ensure process efficiencies.

This role also provides formal and informal program education within facilities as is relevant, and collaborates with facility administration, medical directors, nursing staff and community partners in order to assure process improvement for the care of the advanced heart failure patients. Through knowledge and experience, the Heart Failure Nurse Coordinator should have the skill set to coordinate and oversee the patient care of this high-risk patient population throughout the continuum and can organize and interpret trends in registry data points and focus on continually improving patient outcomes. The Heart Failure Nurse Coordinator can support professional knowledge and healthcare management through effective interactions and communications with clinicians, health care administrators, community agencies and other professionals.

Function/Duties of Position

As an administrator, the Heart Failure Nurse Coordinator is responsible for overseeing internal staff education and competencies and for serving as a resource to all nursing areas for the care of this patient population.

The Heart Failure Nurse Coordinator supports the Heart Failure program in delivering preventive, primary and acute healthcare services to adults with heart failure; provides education that aligns with standards and evidence based research,; contributes to new knowledge and/or technology by supporting or participating in research; and, supports quality improvement efforts in the heart failure program through evidence-based practice, regulatory standards, national registry participation and service line activities. Assure the safe, efficient, high quality and customer-oriented management of patient care to identified patient populations; provide health teaching with an emphasis on prevention of illness and health maintenance as needed to supplement the standard of care; and, perform care coordination for patients to support them through their healthcare journey.

Education

Performs education and coordination of care for high-risk patients as deemed appropriate (inpatient, and in clinics when appropriate). Collaborates with internal and external clinicians and agencies to coordinate transitions of care for patients with heart failure. Specifically provides the following:

• Inpatient rounding and surveillance of patients admitted with heart failure diagnoses.
• Provides individualized inpatient heart failure patient education for select patients (based on needs assessment and heart failure program definition)
• Supports a patient-centered care plan in partnership with the care team.
• Collaborates with care team to provide guideline directed heart failure care
• Works with inpatient teams to optimize transitions of care from inpatient to outpatient
• Enhances healthcare team/provider and patient communication in discharge planning and care transitions to reduce hospital readmissions among patients with heart failure
• Supports inpatient teams in securing heart failure hospital follow up visits and timely referrals to heart failure specialist as appropriate
• Completes hospital discharge follow up phone calls for patients admitted with heart failure
• Demonstrates knowledge of social determinants of health and barriers to implementation of appropriate heart failure management in partnership with the care team.
• Applies culturally sensitive methods when transitioning heart failure patients from inpatient to outpatient.
• Understands risk factors and comorbidities and their contribution to heart failure.
• Understands indications for advanced heart failure, palliative care and hospice referrals
• Educates and supports patients with Advanced Care Planning as needed.
• Provides support for ambulatory HF providers and nurses.
• Recognizes the importance of health-related quality of life (HRQOL) in patients with HF (e.g. cognitive dysfunction, substance use disorder, depression, symptom burden, functional status).
• Coordinates with other health professionals and community resources to optimize care