The Specialty Care Coordinator acts as an advocate to assist disease specific high risk patient populations in navigating throughout internal and external systems in order to facilitate the diagnosis and treatment process. Applies the nursing process through assessment, planning, implementation, and evaluation of the patient in order to provide the optimal level of patient care. The nursing process will extend to the patient’s home as appropriate for in-home education on discharge instructions, medication reconciliation, and disease specific education.
Rounds on high risk patients in the hospital to discuss follow up with the specialty care coordination program
Participates in teaching a class on living with specific disease processes on the inpatient setting
Attends both specialty clinic meetings and mandatory meetings for the care coordination department.
Conducts extensive follow up post discharge on patients in the program including medication reconciliation
Utilizes EPIC to run daily reports for their population and document using standardized templates
Participates in quality improvement initiatives as well as outside committees
May perform patient visits to primary residence for additional education, medication reconciliation, and other nursing functions
Works with high risk population admitted to the hospital, navigating the discharge plan of care and follow up. Continues to reach out to the High Risk Population for support and triage of patient needs