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
Under the limited direction of the attending physician or designee, obtains and records patient medical history; performs physical examinations; orders, evaluates and monitors medical and laboratory diagnostic tests and treatment plans. Performs routine invasive procedures; performs diagnostic and therapeutic procedures. Educates and counsels patient and family members on condition, desired results of treatment plans, expectations during illness and recovery, and other related areas. Participates in the management of patient's care, determining need for consultation to ensure the continuity and quality of care.
PRINCIPAL DUTIES AND RESPONSIBILITIES
1. Preliminary history and physical exam
2. Daily patient visits for routine follow-up
3. Initial nursing and/or medical diagnoses for acute and chronic health care problems to be accompanied by physician consult
4. Ordering and interpreting laboratory and diagnostic tests
5. Prescribing treatments, including medications, within the scope of delegated prescriptive authority.
6. Medication reconciliation
7. Preparation of preliminary discharge summary
Supports the standards set forth in the DMC's 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.
1. Bachelor of Science Degree from an accredited program for Physician Assistants, or the equivalent combination of education and experience, including approximately one year (2000 hours) of clinical internship.
2. Certification from the National Commission of Certification of Physician Assistants, preferred.
3. License as a Physician Assistant by the state of Michigan.
4. Following successful selection/placement into the job, six to twelve months on the job training to perform specialty procedures and responsibilities.
5. Eligible to secure a DEA license upon hire as required by the particular position assignment at the Detroit Medical Center.
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.
1. Analytical ability to monitor data, develop treatment plans and prescribe medications.
Independent judgment to monitor and respond to changes in patient conditions.
2. Interpersonal skill necessary to effectively communicate with patient, family members, medical staff and nursing personnel.
3. Leadership skills including demonstrated willingness to pursue leadership roles with increasing levels of accountability, comfort with decision-making responsibilities, coaching, teaching and counseling skills, and the ability to inspire and build confidence in others and to forge alliances and garner support.
Employment practices will not be influenced or affected by an applicantâ��s or employeeâ��s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.
Internal Number: 1905026453
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.