ACO Nurse Patient Navigator

No nights, no weekends!

VCU Health is seeking an authentic, passionate and inspiring candidate to staff a new Accountable Care Organization (ACO) navigation program, housed in the health system’s Continuum Integration Center in suburban Richmond. This exciting opportunity offers innovation and professional growth and you would be joining an already incredible team, which is expanding to provide this new service offering under the highly-regarded VCU Health at Home brand.

ACO REACH (Realizing Equity, Access, and Community Health) programs are gaining momentum nationwide, because of the benefits for patients and health systems, including increased patient satisfaction, improved patient outcomes, and better performance on value-based metrics. The model operates with a patient-centric focus and a comprehensive, team-based, outcomes-motivated approach to care using population health principles to keep patients healthy.

The ACO REACH Nurse Navigator is a registered nurse who functions as a liaison between the ACO, the patient and the multidisciplinary healthcare team to assist in developing an optimal plan of care for select high-needs Medicare patients.

The Nurse Navigator provides patient-centered care management services for patients with multiple chronic conditions, in conjunction with the patient’s care team.

The Nurse Navigator responsibilities include

a) Support of coordinated care transitions,

b) Provide nurse navigation and chronic care management support for ACO’s identified population, year round,

c) Participate in quality improvement initiatives and proactive panel management,

d) Provide patient and family education on disease monitoring and treatment plans.

SUMMARY

VCU Health’s new ACO REACH Nurse Navigator will join an existing Continuing Care program with staff and processes that are results driven, building on a strong and positive work culture focused on creative thought and continued development. As a member of a team of leaders, this position will help ensure this innovative initiative improves the patient and family experience, so candidate should be enthusiastic about work and delivering his/her best. This enthusiasm and commitment helps form attitudes and characteristics that separate our culture from other organizations.

The successful candidate will have:

• Ability to plan and organize self, others and work in order to achieve objectives and targets.
• Exceptional interpersonal skills, with demonstrated ability to establish, maintain, and leverage positive, productive working relationships with individuals at all levels throughout an organization
• Determination to deliver outcomes and able to overcome obstacles in order to move forward.
• Strong written and verbal communication skills with an acute ability to listen attentively and to communicate effectively to all levels of patient and staff
• Group motivation, creativity and diplomacy
• Highest level customer service standards
• Proven competency in a fast-paced, dynamic environment
• Experience supporting adult patients with complex medical and social needs preferred

Features free parking, and contemporary office accommodations.

Licensure, Certification, or Registration Requirements for Hire: Current RN licensure in Virginia or eligible or compact state Licensure, Certification, or Registration Requirements for continued employment: Current RN licensure in Virginia AHA BLS Certification Specialty Nursing Certification in either Nurse Navigation or area of specialty within one year of hire in position Experience REQUIRED: Minimum of three (3) years of relevant clinical experience in nursing, patient education; case management and/or navigation Previous experience in specialty area Experience PREFERRED: Previous nurse navigation or leadership experience Experience within an academic, teaching hospital Education/training REQUIRED: Baccalaureate Degree in Nursing from an accredited School of Nursing Education/training PREFERRED: Master’ Degree in Nursing from an accredited School of Nursing Independent action(s) required: Follows documented physician/licensed independent provider medical/treatment orders. Practices within the boundaries of the regulations governing the practice of nursing in the Commonwealth of Virginia. Practice is guided by the ANA Code of Ethics for Nursing and established national nursing practice standards. All practice is guided by and follows the VCUHS policies and procedures and established practice guidelines. Organizes and plans work with input from the patient/family with specific outcomes identified. Demonstrates use of sound clinical judgment based on nursing knowledge/experience. Supervisory responsibilities (if applicable): N/A Additional position requirements: Positions are primarily weekday work but may be expected to work into the evening or on the weekend, depending on assignment. May be required to go to all VCUHS locations. Age Specific groups served: As appropriate based on unit assignment Physical Requirements (includes use of assistance devices as appropriate): Physical - Lifting less than 20 lbs. Activities: Prolonged standing, Prolonged sitting, Frequent bending, Walking (distance), Climbing (steps, ladder, other), Reaching (overhead, extensive, repetitive): Repetitive motion Mental/Sensory: Strong recall, Reasoning, Problem solving, Hearing, Speak clearly, Write legibly, Reading, Logical thinking Emotional: Fast pace environment, Steady pace, Able to handle multiple priorities, Frequent and intense customer interactions, Noisy environment, Able to adapt to frequent change

The ACO Nurse Navigator assesses needs and coordinates resources within and outside the VCU Health System to promote optimal health benefits and outcomes (both clinical and financial).

This individual performs duties telephonically and in person (as needed, only on occasion) to engage patients with their care team and provide coordinated care. You will collaborate actively with two dedicated, experienced Medical Directors as well as a Nursing Team Lead and an administrator.

a. Transitional Care Management

The ACO REACH Nurse Navigator will ensure the coordination and communication of a patient’s treatment plan and general status to all care givers during all transitions of care. This position requires advanced nursing knowledge and expertise to identify and implement improvement processes and the ability to direct and implement care coordination plans both in both in-patient and out-patient settings.

• Regularly monitor inpatient and ED discharges for all Medicare ACO REACH patients.
• Contact patients within 2 days of inpatient discharge for care coordination, such as obtaining required specialty and PCP appointments within the required timeline, social worker, home care set-up, and medication reconciliation, and ensure all summary of care documentation is available in the chart at pending visits.
• Alert provider to urgent situations that cannot wait until scheduled follow-up.
• Contact patients within 1 to 2 days of ED discharge for clinically appropriate follow-up.
• Provide appropriate clinical support, counseling, and education.
• Establish rapport with local hospital case management, hospitalist, ER case management, and discharge planning staffs to expedite timely transitions of care and discharge of ACO REACH patients.

b. High-Risk Patient Population Management

Navigator will provide case management review for a prescribed patient panel, and work with the Primary Care Provider, Nurse Case managers, and other members of the patient’s care team focusing on reducing readmissions and addressing chronic disease conditions and social/environmental concerns that may lead to repeat hospital stays/visits.

• Use care gap info to arrange appropriate follow-up prior to clinical deterioration.
• Review readmission rates quarterly to see the trending with outreach, appointment completion, and impact on the readmission rates.
• Coordinate care management services for high-risk patient populations identified by claims data (frequent admissions/ED visits).

c. Clinical Quality Management

Navigator will identify and interpret care gap info to ensure that quality measures are being met and costs are being managed while working on the patient’s care.

• Assure clinical processes support ACO REACH quality measures.
• Participate in quality improvement activities under the direction of the Team Lead- VCU Continuing Care to optimize patient outcomes.
• Lead proactive panel management updates in Epic
• Assist with the development of a system for electronic and automatic patient reminders needed for care management.
• Help direct patients on the best pathway to treatment.

d. Patient and Family Education

Navigator will provide high frequency of contact with the very high risk ACO patients and their care givers for education of health promotion and self-care skills as well as facilitating compliance with the required quality measures for all ACO patients.

• Provide clinical support, counseling, and education.
• Alert provider to urgent situations that cannot wait until scheduled follow-up through Securechat and Epic.
• Provide self-management education and support in chronic care management.
• Promote Advance Directives
• Maintain educational materials and references for patients and families (aspirational)

EEO Employer/Disabled/Protected Veteran/41 CFR 60-1.4.