|Company Name: Dialysis Clinic, Inc., (DCI)
|Job Title: CKD Transitional Care Coordinator (RN)
|Required Education: Not Specified
|Job Type: Health Care
|Required Experience: Not Specified
|Base Pay: N/A
|Required Travel: Not Specified
|Location: Nashville, TN
|Employee Type: Full-Time
|Manages Others: Not Specified
|Relocation Covered: Not Specified
|Industry: Healthcare - Health Services
Learn More About DCI
We are a service organization. The care of
the patient is our reason for existence.
To be considered for the position, please (1) upload your resume, (2) complete the application in its entirety, and (3) answer the screening questions. Summary
: The TCC Transitional Care Chronic Kidney Care Coordinator oversees the Pre-ESRD DCI Chronic Kidney Disease (CKD) Program. The primary goal of the CKD program is to delay the progression of kidney disease and the need for renal replacement and to best prepare the patient if the need for renal replacement arises. To accomplish this, the Transitional Care Coordinator will provide education to all partners in the care of kidney patients and coordinate services to transition the patient to renal replacement if needed.
Key roles for the Coordinator will include:
- Identifying early-stage kidney failure patients and building relationships with them.
- Education of patients and families, education of healthcare providers throughout
the delivery system.
- Evaluation of current disease management approaches and recommendations for change
- Development and maintenance of a database to evaluate CKD program effectiveness.
This role requires substantial self-direction and autonomy, superior communications and teamwork skills, and a passion for improving the lives of CKD patients. Essential Duties and Responsibilities
:Transitional Care Coordinator:
- Follows and coordinates care of the patient as he/she approaches the need for renal replacement through the first 90 days of renal replacement.
- Provide patient education throughout the hospital stay, including but not limited to, access care, limiting infection risks, fluid control
- Coordinates dietary instruction with Registered Dietitian
- Coordinates education with social worker to address emotional, adjustment, financial issues, insurance issues, employment issues, and other psycho-social needs.
- Coordinates vascular access placement if vascular or peritoneal access does not already exist.
- Medication compliance. The discharge medications will be reviewed with the nephrologists to ensure accuracy, with the patient to ensure understanding. The DCI Pharmacist will be available to assist with patient understanding and to apply for patient assistance programs if financial issues exist.
- Scheduling appointments with physicians, testing, other services, confirming the patient knows where to be, who to see, and has the means to get there
- Phone or home follow-up with new patients within 24-48 hours of discharge and at least weekly through the initial12 weeks of treatment. Each discharge plan is customized to the individual patient and identifies the resources and level of change that patients and their caregivers are willing to accept and execute.
- Collects and enters data for each patient to assess attainment of program goals
CKD Education coordinator responsibilities include:
- Provides a summary of activities to Administrator monthly
- Provides a summary of activities at the Governing Body meeting
- Works with other DCI Integrated Care Coordinators, sharing outcomes, activities and ideas, keeping the program within the standards set my DCI.
- Builds alliances with hospitals and other providers of care to renal patients
- When opportunities present, develops proposals for alliances with hospitals, insurers, and others entities with shared goals
- Observes strict confidentiality of patient and personnel information.
- Conducts self in a professional manner as demonstrated by appearance and attitude, by maintaining a clean and orderly environment, and by dedicating work time to meet patient and DCI needs.
- Recognizes and responds appropriately to emergency situations.
- Understands clinic agreements and contracts.
- Follows the facility attendance policy (absence and tardy).
- Displays a positive attitude toward patients, co-workers, physicians and DCI.
- Assists in meeting clinic goals.
- Performs other duties as assigned.
- Education of health care professionals (hospital staff, nurse practitioners, case managers, etc.) to identify risk factors of CKD and understand referral opportunities for patients
- Education of patients and families in the community, identifying those at risk and following referral protocols. (Outreach)
- Educate patients and families about treatment options, including transplantation, home therapies, and incenter therapies. (individual and group education)
- Encourage transplantation as the treatment of choice
- Encourage early placement of fistula, regardless of treatment option chosen….
To perform this job successfully, an individual must be able to perform each essential job duty satisfactorily. The requirements listed below are representative of the knowledge, skills and abilities required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Education and Experience:
- Graduation from nursing school. Minimum of 3 years hemodialysis experience, at least one year in a supervisory position.
- CNN or equivalent certification in nephrology nursing is strongly preferred.
- The ability to teach to different education level audiences, the ability to use Microsoft applications to track progress and develop reporting tools.
Since this is a healthcare environment, there is the possibility of exposure to infectious / contagious diseases, needle sticks and blood and body fluids. Further information about this position’s specific work environment and exposure category will be provided during orientation. This position is classified as Category I.DCI offers a very competitive benefits program.DCI is an Equal Opportunity Employer/AAVEVRAA Federal Contractor
The primary responsibility of DCI is to perceive, initiate and provide comprehensive patient care. We serve society by providing care for patients with end-stage renal disease. Our goal is complete patient rehabilitation. We recognize the patient as an individual resulting from his/her genetics, life experience, habits, beliefs, emotions; and as a member of his/her family, and the community. The patient deserves the highest standard of care possible regardless of race, status or creed. The application of comprehensive care is on a personal level. We become acquainted with our patient as a person and seek to understand his/her problems and needs - physical, emotional, spiritual and social.
Through a team approach, each staff member performs functions within his or her capabilities in his or her defined role based on the specific needs of the individual patient. Patient care is assessed, planned, implemented, and evaluated with the consistent aim of improving care and finding more efficient and effective methods for delivery of care. Realistic goals, which promote safe, therapeutically effective and individualized care for each patient, are defined in the patient care plan. These goals adhere to quality standards of care within the framework of defined policies and procedures. The team strives to provide the highest quality of patient care possible through the utilization of available human and material resources. There is, however, a further responsibility to which DCI is devoted. DCI was established as a non-profit corporation, hopefully to generate funds for research in order that the methods for treatment of ESRD patients might be improved. We are not content to dialyze the next group of patients in the same imperfect way that the last group was dialyzed without at least making the attempt to better the patient's lot through research. As a corollary to this, education of ESRD health care professionals is another goal to which DCI resources are dedicated to support. DCI's philosophy has always been a commitment to patients.
Patients complete a financial profile, which aids the social workers in directing them to community services to assist them. Patients are also assisted in acquiring and maintaining primary and supplemental insurance. If a patient does not have primary or secondary insurance, every effort is taken to find a DCI facility that can accept the financial burden of an uninsured patient. DCI endorses the patient's right to choose the facility and the mode in which the patient's ESRD should be treated, i.e., dialysis or transplant. To help insure that those patients desiring transplant may be offered this form of treatment, DCI founded and remains closely affiliated with DCI Donor Services, Inc., which operates independent organ procurement agencies and also contributes to research to improve methods of immunosuppression. We are a service organization. The care of the patient is our reason for existence.
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