Summary: The Overnight Transition of Care (TOC) APP serves as the clinical expert for assigned nursing areas, with a focus on supporting transitions of care overnight to promote safety, improve quality of care, and speed recovery. The TOC APP helps patients reach Plan of Care goals, supports all other patient care initiatives progressing toward discharge, and provides discharge information need to transition from hospital to home and/or manage health needs post-discharge. The TOC APP works collaboratively with medical staff using a team-based approach and assists with the treatment of both acute and chronic conditions through comprehensive history taking, physical exams, physical therapy, and ordering tests and therapies for patients within their scope of practice.
Manage patient care overnight in collaboration with the medical team
Make rounds nightly on all inpatients admitted by the Transition of Care APP to identify and manage patient needs; speak with patients and families, educating them on their progress
Follow established protocols to provide patient care activities as needed to resolve patientï¿½s needs
Attempt immediate resolution of patientï¿½s issues that could lead to readmission, whether presented in person or by telephone; elevate issues to the Department Manager/Director for assistance as deemed necessary and appropriate
Maintain open lines of communication with health care professionals regarding patient/family needs and identify areas of improvement throughout the hospitalization
Work collaboratively with the admitting physician, as appropriate, to complete Transition of Care duties including consults, history and physicals, and progress notes through 0700 on the morning following the admission, at which time the admitting physician will take over total medical care of the patient.
Advocate for resources on the patientï¿½s behalf as appropriate and serve as liaison between patients and the hospital to ensure satisfaction with services
Ensure that appropriate labs, radiographic studies, diagnostic tests, pre-op clearances, and procedures are ordered, and results are followed up
Review Medication Reconciliation and address any fallouts from the time admission orders were placed until 0700 the following morning.
Complete accurate and relevant documentation
Identify patients at high- and moderate-risk for readmission and communicate to relevant staff
Identify patients who are potential discharges and communicate to relevant staff
Prepare patients for discharge and transition of care
Critically think through all diagnoses and assist the admitting Physician in preparing the patient for a safe and complete Transition of Care to the In-Patient setting; if items are missing from the initial work-up plan, add them, including making calls to physician(s) for missing medications, etc.
Coordinate with staff to solve any problems regarding transition of care, focusing especially on the appropriate utilization of order sets, protocols and clinical pathways.
Ensure that patients being discharged have received their education, follow-up appointments, and appropriate referrals by their admitting physicians; teach the patient/client and family/caregiver self-care techniques as appropriate; provide medication, diet, and other instructions; and recognize and utilize opportunities for health counseling with patients and caregivers
Meet with ANM and all charge nurses to apprise them of the transition plan and ensure that they understand the plan, especially for the nights and weekends
Communicate and collaborate openly with physician, home health agency, skilled nursing facility and other health care team members as needed regarding transition of care from the ED to the In-Patient setting.
Run daily readmission reports to identify patients who are readmitted within a 30-day timeframe
Maintain a clean, safe, secure, and quiet environment
The Nurse Practitioner (NP) is an advanced practice nurse, who utilizes advanced knowledge and clinical expertise in providing primary and/or specialized health care services to individuals, families, groups and communities across the health-illness continuum. Diagnostic reasoning, advanced therapeutic interventions and education are key elements in the direct provision of care using a collaborative model. The nurse practitioner works as an autonomous practitioner or in collaboration with a physician, and is directly accountable for making clinical judgments using independent and interdependent decision-making skills. The nurse practitioner's primary focus is on the provision of direct and indirect patient care in managing the health care needs of the identified client population(s). The nurse practitioner provides care to a specific patient population using advanced skills in physical exam, diagnosis and treatment. The nurse practitioner writes medical orders (medications, tests and invasive procedures) and may perform invasive procedures, and perform or assist with surgical procedures; subject to internal and external rules and regulations credentialing. The nurse practitioner also functions as a consultant, educator, researcher, resource and role model for patient, families, community, nursing personnel and other health care providers. The nurse practitioner evaluates the quality of care rendered; analyzes and promotes system changes to enhance quality of care and organizational effectiveness/efficiency; conducts/utilizes research to promote health and improve health care delivery. The nurse practitioner assumes responsibility for own professional development. Appropriate privileges are required to prescribe pharmacological and medical interventions. The nurse practitioner obtains privileges to practice within the Detroit Medical Center as an Allied Health Professional through the Detroit Medical Center Medical Staff Organization, according to internal and external rules and regulations. A.?? PRACTICE 1. Assesses the health status of patients through eliciting comprehensive health histories, performing physical exams and analyzing data to formulate appropriate diagnoses. Develops prioritized, comprehensive problem list and prioritizes/prescribes interventions and diagnostic tests, when appropriate, in collaboration with a physician or according to established standards. Consistently collects patient data, which is prioritized according to the patient's immediate condition or needs. 2. Identifies expected patient outcomes and develops appropriate plan of care to manage patients' health problems, promote health maintenance and prioritizes multiple patient needs. The plan of care is developed in collaboration with the patient, family and other health care professionals. The plan of care is documented and specifies appropriate diagnostic and therapeutic strategies to attain expected outcomes which are individualized, consistent with goals of care, cost-effective, reflective of current scientific knowledge and which anticipate and address the continuing needs of the patient. 3. Prescribes and implements interventions identified in the interdisciplinary plan of care. Interventions may include a variety of therapeutic interventions, including diagnostic tests, pharmacologic and non-pharmacologic interventions, invasive procedures, providing patient/family education and counseling, and initiating health care and community referrals. 4. Evaluates and documents patient progress toward the attainment of expected outcomes utilizing interdisciplinary collaboration, appropriate quality indicators and multiple sources of data, including the patients' assessment of progress. Coordinates and facilitates continuity of care that crosses institutional and organizational boundaries, as required. 5. Acts as a patient/family advocate to ensure health care services are delivered in an ethical and culturally sensitive manner. B. CONSULTATION 1. Acts as a consultant to patients, families, the community, nursing staff, medical staff and other health care providers by providing clinical expertise. 2. Promotes the integration of a nursing perspective in planning, policy making and problem-solving 3. Provides consultation to various agencies and groups (i.e., government, planning groups, health institutions, community groups, policy makers, organizational leaders, teaching institutions and other educational groups/agencies). C. EDUCATION 1.?Assesses the knowledge, skills and ability of the nursing staff to provide quality patient care. Provides education opportunities to develop and enhance performance, problem-solving and critical thinking skills of nursing staff. 2.? Designs, implements, coordinates and evaluates materials and programs for clients, health care professionals and the community, based on identified needs. 3.?????? Educates nursing staff and other health care providers in the development, implementation and evaluation of teaching strategies for patients/families. 4. Instructs patients/families/caregivers about medical condition, management, follow-up care, medications, illness prevention, health promotion, coping strategies. The intent is to increase knowledge and the ability to manage the illness and maximize coping strategies for patients, families/caregivers. 5.?????? Precepts, teaches, coaches and mentors students, nurses and other health care providers. D. RESEARCH 1. Conducts research independently or in collaboration with other nurses and/or other disciplines. 2. Analyzes and disseminates relevant nursing research. Applies research findings in clinical setting to improve practice. E. MANAGEMENT/LEADERSHIP 1. Acts as an independent practitioner. Utilizes independent judgment to effectively recommend changes in clinical practice and/or prescription of nursing interventions in patient care. 2. Utilizes continuous quality improvement to effect system changes. Integrates clinical and management skills with fiscal responsibility. 3. Provides proactive leadership to attain excellence in clinical nursing practice and quality patient care at the departmental, divisional and organizational levels. 4. Supervises clinical practice to ensure effective, efficient quality care delivery. F. PROFESSIONAL Maintains current knowledge and clinical expertise through ongoing involvement in professional activities. Engages in collaborative appraisal of professional practice. Models professionalism and positive guest relations. Engages in activities that enhance/advance the profession of nursing. Sets professional goals and demonstrates achievements. COMPLIANCE STATEMENT Supports the standards set forth in the DMC Code of Conduct by creating an atmosphere of commitment to legal and ethical standards, and as directed, implementing external and internal audit recommendations. Monitors activities to ensure compliance with applicable laws, regulations JCAHO requirements, and DMC policies and procedures. *The essential functions of this job include but are not limited to those marked with an asterisk. [BRASSRING IMPORT 10/25/16]
1.?Registered nurse licensure to practice in the state of Michigan. 2. State of Michigan Nurse Specialty Certification as a Nurse Practitioner. 3. Master's degree in nursing from an accredited nurse practitioner training program. 4. Two years clinical experience as a professional nurse. 5. National certification in advanced practice nursing specialty from one of the following certification bodies: ??American Nurses Credentialing Center (ANCC) ??National Certification Board of Pediatric Nurse Practitioners and Nurses (NCBPNPN) ?National Certification Corporation for the Obstetric & Gynecologic & Neonatal Nursing Specialties (NCCOGNS) ???American Academy of Nurse Practitioners (AANP) ???Oncology Nursing Certification Corporation (ONCC) 6. Eligible for approval of privileges to practice within the Detroit Medical Center as an Allied Health Professional through the Detroit Medical Center Medical Staff Organization. Application for Allied Health Professional credentialing must be submitted to the Detroit Medical Center Medical Affairs Office upon hire. 7. Prior to obtaining privileges through the Detroit Medical Center Medical Staff Organization, the nurse practitioner may: a. See patients under the direct supervision of a nurse practitioner, who has obtained privileges through the Detroit Medical Center Medical Staff Organization, or the attending physician. b. Prescribe medications and treatments, and order diagnostic tests as a delegated responsibility from the attending physician. The orders will be written as verbal orders and must be co-signed by the supervising nurse practitioner or attending physician within 24 hours. 8. In accordance with State of Michigan administrative rules R338.10403, ?Only nurses certified in a nursing specialty field may hold themselves out to the public as nurse specialists using the title nurse anesthetist, nurse midwife, or nurse practitioner. Conduct contrary to this rule is deemed a violation of sections 16221(g) of the act.? Therefore, prior to obtaining national certification in an advanced practice nursing specialty and State of Michigan Specialty Certification as a Nurse Practitioner, the title nurse practitioner may not be used and newly graduated nurse practitioners will be hired under Graduate Advanced Practice Nurse job description. LEGAL SCOPE OF PRACTICE 1.?In the state of Michigan, certified nurse practitioners have the scope of practice of both a Registered Nurse and a Nurse Practitioner. 2.??A certified nurse practitioner may prescribe/write medical orders according to collaborative practice agreement with a licensed physician. The physician?s name must appear on the prescription along with the NP?s name and signature. Example: Sarah Smith CNP/Alex Jones, MD. 3.?According to Michigan law, nurse practitioner?s have delegated authority to prescribe non-controlled and controlled substances II-V as a defined in Michigan Administrative Code Rules 338.2305 & 338.108b. 4.?According to Michigan Public Health Code Part 178, Physical Therapy, 333.17820: Physical therapy may only be provided upon the prescription of a physician, dentist or podiatrist. 5.??Nurse practitioners may perform medical procedures as defined in collaborative practice agreement with a licensed physician upon: a. Initial training in performance of specific procedure, which shall include appropriate didactic instruction and demonstration of clinical competence in performing the procedure. b. Documentation of ongoing clinical competence in performance of specific procedure. 6. Nurse practitioners may bill for professional services under physician provider ID number or may bill under own provider ID number, according to requirements of individual insurers. For example, as of 5/9/03, nurse practitioners may obtain & bill under their own provider ID numbers for Medicare, Medicaid, Tricare, and Blue Cross/Blue Shield of Michigan. [BRASSRING IMPORT 10/25/16]
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Internal Number: 1905026451
About DMC Harper University/Hutzel Women's Hospital
“Tenet Healthcare Corporation is a diversified healthcare services company with 115,000 employees united around a common mission: to help people live happier, healthier lives. Through its subsidiaries, partnerships and joint ventures, including United Surgical Partners International, the Company operates general acute care and specialty hospitals, ambulatory surgery centers, urgent care centers and other outpatient facilities. Tenet's Conifer Health Solutions subsidiary provides technology-enabled performance improvement and health management solutions to hospitals, health systems, integrated delivery networks, physician groups, self-insured organizations and health plans.