(Clinical Continuity) ACCESS NURSE

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POST DATE 8/10/2016
END DATE 12/15/2016

Massachusetts General Hospital(MGH) Boston, MA

Boston, MA
AJE Ref #
Job Classification
Full Time
Job Type
Company Ref #
Entry Level (0 - 2 years)
Bachelors Degree



The Amyotrophic Lateral Sclerosis multidisciplinary clinic is a busy and vibrant ambulatory clinic in the department of neurology. The devoted and close-knit team consists of 8 physicians, 1 nurse practitioner, 4 nurses, 2 physical therapists, 2 speech pathologists, 2 respiratory therapists and a clinic coordinator. Patient volume is high, and the team uses a multi-disciplinary team approach.

Under the supervision of the Nurse Manager, the Clinical Continuity (CC) Nurse will work closely with the Neurological Clinical Research Institute and MGH ALS Clinic leadership to expand the Telemedicine for the Care of People with ALS (TelePALS) program. The TelePALS program attempts to develop, assess, and implement novel care delivery techniques, including technology-based mobile health solutions, to more fully integrate ALS care into patients lives. The CC Nurse will help plan, refine, and extend care activities beyond the walls of the clinic. The CC Nurse will also take the lead in ensuring continuity of care for patients who are unable to travel to the MGH clinic and interact with community and home health providers to more fully integrate care and improve patients experience.

The position requires a high degree of innovation. The ideal candidate is flexible, independent, and willing to participate in multiple activities while providing support to patients by working with the team. Candidates must have strong communication skills and the ability to converse comfortably with patients and their caregivers.


FACILITATING CONTINUITY OF CARE: Oversee the expansion of the TelePALS program and spearhead the development of an MGH ALS Clinic without walls in an effort to extend multidisciplinary ALS care

* Provides clinical home visits with homebound patients and appropriately notifies provider/other team members with updates on the patient

* Work alongside a patient services coordinator to fully implement the Telehealth program and increase the number of video televisits

* Develop and maintain tracking system to determine program effectiveness, with support from internal data management and IS.

* Develop and implement systems to standardize Telehealth and Homebound patient care.

* Explore innovative care models and novel mobile health technology for patients from their homes, reducing the burden on patients to come in to MGH, while also increasing clinical care.

* Collaborates with outside facilities and clinical staff for certain patients, and also to provide general information about caring for ALS patients.

* This may include hospitals, PCPs, VNA, Hospice, and private help.

* Organize and develop the expansion of the Comprehensive ALS Support Team (CAST) initiative (which is a collaboration with Partners VNA for increased communication and training for home/community healthcare providers regarding patients with ALS) to a larger group of home care and hospice organizations

* Explore innovative ways to disseminating patient and community education materials as a means to enhance continuity of care.


* Provide support and assistance with challenging patient/physician situations

* Actively participate in network development initiatives and communicate initiatives back to access team for relationship building within MGH affiliate networks.

* Participate as requested in MGH and Partners quality initiatives.

* Participate in various hospital and system committees as assigned.

* Meets routinely with NCRI and ALS clinic leadership to report on activities, patient satisfaction, problems, and recommendations.

* Meets routinely with Associate Directors of the MGH NCRI to review progress and overall performance of the program.

* Act as a liaison to the web development team at MGH, improve the clinics web presence, and manage the clinic newsletter.

* Work alongside the Research Access Nurse to integrate research opportunities into the care plan for all people with ALS who express interest.


* Professional knowledge: Clinical, healthcare knowledge to enable effective interactions and communications with patients, caregivers, clinicians, and healthcare administrators.

* Time Management: Exceptional organizational skills and ability to prioritize effectively and complete tasks, Flexibility to handle multiple tasks and deadline pressures.

* Highly motivated, independent, innovative, and capable of performing in a complex environment

* Strong sense of initiative and perseverance to carry through to completion of tasks, Demonstrates forthrightness and integrity.

* Ability to identify issues/projects and initiate plans to address asking for direction when appropriate

* Ability to develop a common vision for diverse communities, communicate effectively, and take ownership and responsibility for activities.

* Interpersonal/communication: Excellent interpersonal, written and oral communication, and public speaking skills, Good command of English language, including medical and scientific terminology.

* Information Systems/Technology Skills: Exceptional computer skills (including operating systems, database, electronic mail, Internet, spreadsheets, and other office management systems), Ability to maintain databases and associated analysis and reporting.

* Quality Assurance: Skills to work efficiently and effectively and strive to do so in all aspects of position.

* Critical Thinking/Decision Making: Ability to appropriately evaluate all aspects of a situation and to independently make appropriate and timely decisions.

* Personnel Management: Ability to coordinate among diverse populations.

* Discretion and Confidentiality: Ability to handle sensitive and confidential matters discreetly and to ensure confidentiality guidelines are maintained by staff.

* Safety/Compliance: Knowledge in aspects of safety applicable to position, Knowledge of and compliance with institutional, JCAHO, HIPAA, and other regulatory bodies standards.


* Current, valid licensure as a registered nurse in the Commonwealth of Massachusetts.

* Basic Life Support (BLS) current


* Bachelors Degree in Nursing.


* Relevant nursing experience preferred.

Massachusetts General Hospital is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. Applications from protected veterans and individuals with disabilities are strongly encouraged.