Pre-Heart Transplant Nurse Coordinator 24 Hours BWH

QUALIFICATIONS:
* 1. Graduate of an approved school of nursing with current registration in Massachusetts required. BSN required.
* 2. Must have 5 years recent experience (recent within 2 years) in the care of advanced heart disease or cardiac transplant patients required.
* 3. Prior Transplant Coordinator (1 year or more within the last 5 years) experience strongly preferred.
* 4. Ambulatory experience (current defined as within the last 12 months) with telephone triage (assessment, management, planning, and execution) strongly preferred.
* 5. Knowledge of community resources and post/non-acute care providers preferred.
* 6. Familiarity with discharge and resource planning preferred. Active membership in a related professional organization is recommended.

Support and Extension of Clinical Activities:

* Coordinates out-patient care of pre heart transplant patients, including participation in multidisciplinary rounds, documentation of assessment and plan in the medical record, organizational efficiency and discharge planning and follow-up.

* Facilitates interactions of the multidisciplinary team members, including physicians, social work, transplant pharmacist, nutritionist and outside consultants. Acts as a liaison between members of the inpatient care team and outpatient management team, including heart transplant nurse practitioners. Communicates with referring physician team to keep them up-to-date regarding patients clinical status.

* Telephone contact with patients to assess clinical status, monitor response to therapy, adjust medications in consultation with clinical providers, and organize outpatient or inpatient follow-up as needed.

* Assists in urgent patient triage, including emergency room visits and transfer from outside institutions, and documents care provided.

* Provides education to transplant patients and family members regarding important aspects of care, including but not limited to evaluation, waitlist, peri transplant, activity, diet, medication adherence and healthcare follow-up.

* Helps to maintain current supply of patient/family education materials.

* Sets up consults with specialty providers, follows up consult recommendations and communicates results to patient and other providers.

* Assists with communication and correspondence to/from patients, employers, pharmacies and insurance providers with regards to medication prescriptions, cardiac rehabilitation, disability, family medical leave, and payment coverage. May also communicate and correspond with other providers (e.g., utility company, telephone company) as dictated by patient needs. These duties may require telephone calls, faxes, mail and/or e-mail. Meets regularly with medical program director and nurse practitioners to facilitate quality and process improvement initiatives.

* As requested, implements and assesses initiatives and summarizes results for team.

* Attends weekly clinical meeting and heart transplant clinics as needed.

* Works with financial counselor and social work to assist patients/families in need of financial support, insurance coverage, medications, housing and/or utilities.

* Cross -trains to assist in covering for the in-patient nurse coordinator and post-heart transplant nurse coordinators.

* Ability to work on-campus wearing appropriate PPE when caring for patients requiring enhanced precautions.

* Ability to triage and manage high patient volumes with complex needs in a crisp and pithy manner.

* Other duties as needed and assigned by nursing, director, and transplant leadership.

Organization of Patient Care:

* Reviews referral documentation and medical records and regularly meets with the Program Directors to identify potential transplant patients.

* Contacts referring physician practices to determine current status of patient and provide ongoing updates.

* Coordinates pre-transplant evaluation with primary care providers.

* Collaborates with all members of the transplant team for seamless coordination of newly referred patients for heart transplant evaluation.

* Coordinates and facilitates New Patient and Pre-Transplant clinic sessions. Works with providers to ensure completion of necessary testing at appropriate stages of evaluation.

* Participates in the longitudinal informed consent process with patients in the consultative and evaluative phases of heart transplantation.

* Ensures provision of patient education materials, reviews key elements of the education process, including risks, benefits of transplant, the evaluation procedure, risks of immune suppressing medication, alternative treatment options, and other elements of the informed consent process.

* Ensures completion of all documentation as pertains to informed consent. Facilitates completion of the evaluation for heart transplant candidacy.

* Ensures multi-disciplinary participation in the pre-transplant phase of transplant per protocols and policies.

* Reviews evaluation testing and identifies outstanding items.

* Works with administrative coordinator and referring physician to coordinate testing for presentation at multidisciplinary team meeting for discussion of candidacy.

* Compiles and summarizes evaluation results for presentation at multidisciplinary team meeting utilizing Epic and regulatory databases.

* Documents results of discussion at Multi-Disciplinary Selection Committee Meeting.

* Completes all required documentation related to determination of candidacy. Communicates with patient and referring physician regarding recommendations of the Multi-Disciplinary Selection Committee.

* Facilitates and coordinates educational programs for patients in the consultative and evaluative phases of transplant.

* Provides education for the patient and family as needed, utilizing appropriate resources.

* Reviews, revises, and initiates development of patient teaching materials with other team members.

* Works closely with and collaborates on the workflow of the Pre-Transplant Administrative Coordinator to facilitate the care of patients in the consultative, evaluative, and wait list phases of the heart transplant process.

* Works with financial coordinator to provide medical information as requested by third party payers.

* Works with financial coordinator, social work, and other means of assistance as needed.

* Communicates patient information to the care team via appropriate documentation and team conferences.

* Conducts post acute patient follow-up to ensure execution of follow-up care, non-acute plan of care optimal service utilization and quality of care and service to patient pre and post transplant.

* Manages and continually improves systems to provide information on patients current level of care/changes in clinical status to Heart Transplant Team, referring physicians, financial coordinator/third party payers, UNOS and others. Works with Physicians Directors to review, Revise, and initiate changes to improve the pre-transplant management process.

Quality of Care:

Participates in multidisciplinary patient care conference and medical management meetings. Documentation is clear, complete, concise, and organized in tis presentation, demonstrating skill in the nursing process. Observes principles of infection control in nursing practice, demonstrating awareness of potential/actual risks of infection and modes of transmission. Participates with all assigned QAPI processes as directed. Participates with all assigned e-care improvement initiatives as directed. Seeks ongoing feedback to ensure nursing

practice remains at the highest level.

Data Activities:

Collects demographic and clinical data from hospital computer system, administrative sources, charts and weekly conferences and enters data into heart transplant databases as needed, including the United Network for Organ Sharing (UNOS) system. Provides research nurses with clinical data on subjects enrolled in research studies. May be asked to assist in writing summaries for administrative or clinical purposes as requested by the Nurse Manager, Nurse Director, or Medical Director of the Heart Transplant Program.

SKILLS/ ABILITIES/ COMPETENCIES REQUIRED:
Ability to work independently while collaborating with others in the care of complex patients with advanced heart disease, multiple co-morbidities, and eventual lung transplantation. Excellent written and oral communication skills to work with individuals from various fields of expertise, including physicians, nurses, hospital administrators and outside clinical and administrative providers. Flexibility, excellent judgment, and the ability to work independently and as part of a team are essential. Excellent organizational abilities to formulate and meet rigorous clinical timetables. Must display interpersonal skills and ability to work as part of a multidisciplinary team. Maintains communication with other transplant programs in order to keep abreast of current information. Utilizes time and materials effectively. Self-motivated individual with a commitment to excellent care. Team motivated individuals who assists colleagues if and when needed with ask or direction.

WORKING CONDITIONS:
On campus at BWH Main Campus or off-site locations as directed by the Nurse Manager or Nurse Director. This includes in the state of MA and outside the state of MA which may require further licensure in those states. Administrative office, outpatient and inpatient settings as needed. Working conditions may include busy and stressful patient care encounters, and environments where there may be exposure to communicable diseases and hazardous materials.
SUPERVISORY RESPONSBILTIES:
None.
HOSPITAL WIDE RESPONSIBILITIES:
Works within legal, regulatory, accreditation and ethical practice standards relevant to the position and as established by BWH/Partners; follows safe practices required for the position; complies with appropriate BWH and Partners policies and procedures; fulfills any training required by BWH and/or Partners, as appropriate; brings potential matters of non-compliance to the attention of the supervisor or other appropriate hospital staff.

PROFESSIONAL ATTRIBUTE:
Establishes effective professional relationships with other members of the healthcare team. Establishes effective professional relationships with patients, families, and referring providers. Serves as role model and resource for other staff, providing assistance with the care coordination process, clinical skills and patient teaching. Maintains communication with other transplant units programs in order to keep abreast of current information. Maintains professional relationships with appropriate professional organizations. Regularly incorporates new scientific findings in specific area of expertise into clinical practice. Maintains awareness of new developments in the specialized area and participates in research activities.
PARTICIPATORY MANAGEMENT:
Utilizes time and materials effectively. Participates in the orientation of new staff members, students and others as appropriate. Provides input into the evaluation of other staff as appropriate. Adheres to hospital and departmental policies. Recommends changes in policies and procedures through appropriate channels. Participates in determining and implementing goals and objectives for the transplant program, and in the periodic review of the program.