Facilitates Care Transitions Intervention to include interdisciplinary collaboration across transitions and coaching the patient and caregiver to play a central active role in the formation and execution of the plan of care. Facilitates the intervention by identifying and meeting with patients in the hospital, performing home visits and follow-up phone calls. Introduces patient to self-management tools with the following goals: Medication self-management; Use of a dynamic patient-centered record; Primary Care and Specialist Follow-Up; Knowledge of Red Flags.
Graduate of accredited ADN or BSN program, Registered Nurse.
Minimum 1 year clinical experience as RN
Prefer 5+ years RN experience
Experience in multiple settings working with chronic care preferred
Experience in public health, home health, community health or case management a plus
CHRISTUS HEALTH is an international Catholic, faith-based, not-for-profit health system comprised of almost more than 600 services and facilities, including more than 60 hospitals and long-term care facilities, 350 clinics and outpatient centers, and dozens of other health ministries and ventures. CHRISTUS operates in 6 U.S. states, Colombia, Chile and 6 states in Mexico. To support our health care ministry, CHRISTUS Health employs approximately 45,000 Associates and has more than 15,000 physicians on medical staffs who provide care and support for patients. CHRISTUS Health is listed among the top ten largest Catholic health systems in the United States.