ONCOLOGY CARE COORDINATOR
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POST DATE 9/12/2016
END DATE 10/31/2016
Yale New Haven Health
New Haven, CT
To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values integrity, patient-centered, respect, accountability, and compassion must guide what we do, as individuals and professionals, every day.
The Oncology Care coordinator reports to the Director of Ambulatory Care Coordination with a matrixed reporting relationship to the Executive Director of Smilow Cancer Hospital. He/she works in collaboration with Oncology Physicians, clinic/practice staff, homecare staff, Navigators, and other healthcare professionals to develop, implement, evaluate, and revise the delivery of care management services to better serve geriatric patients (Medicare recipients) receiving chemotherapy. The Oncology Care coordinator will assess the functional, social, and health needs of this population and will work with the patient's physicians, community providers and family to ensure that all of the patient's care needs are met. The Oncology Care coordinator works from within the context of a patient-centered, team approach to promote: timely access to needed care, comprehension and continuity of care, and the enhancement of patient and family wellbeing. Nursing activities include, but are not limited to systematic analysis of health data, care plan development, health education and advocacy, and collaborating with system and community partners to promote the comfort and safety of this population. The Oncology Care coordinator will work with the team to ensure that care can be provided in the ambulatory environment, and to prevent avoidable emergency department visits and hospitalizations.
* 1. Effectively works in collaboration with the patient's oncologist, primary care physician and team and other clinicians, family members, caregivers, and visiting nurse services to develop an individualized plan of care for the patient and communicate this plan to all members of the patient care team.
* 2. Demonstrate and apply knowledge of the philosophy/principles of comprehensive, community-based, patient-centered, developmentally appropriate, culturally sensitive, and linguistically appropriate care coordination services
* 3. Assess patient and family needs and ascertain which needs are unmet.
* 4. Research, find, and link resources, services, and support for patient and family.
* 5. Serve as the contact point, advocate, and informational resource for patients, family and community providers.
* 6. Create ongoing processes for patients and families to determine and request the level of care coordination support they desire at any given point in time.
* 7. Serve as a quality improvement team member; help to measure quality and to identify, test, refine, and implement practice improvements.
* 8. Coordinate efforts to gain family feedback regarding their experiences of health care; participate in interventions which address articulated needs.
* 9. Provide are coordination, referral, and follow-up to geriatric patients receiving chemotherapy and their families/caregivers. Evaluate outcomes, effectiveness of care plan, and makes changes as necessary on micro and macro levels.
* 10. Responsible for initial and ongoing education of patients and families on Advanced Care Planning including options and process for completion of advanced directives.
* 11. Document patient assessment and intervention data in medical record. Use established medical record forms, databases, and documentation practices. Learn and adopt any additional technology platforms utilized by YNHHS for the management of care across the continuum.
* 12. Advocate on behalf of vulnerable older adults and their families, participate in assessing and evaluating health care services to ensure that people are informed of available programs and services and are assisted in utilization of those services.
* 13. Additional RN Duties:
* 13.1 Maintains confidentiality of patient, personnel, and institutional information.
* 13.2 Demonstrates effective organizational skills.
13.3 Demonstrates clinical leadership.
13.4 Demonstrates expert skills that include flexibility, priority setting, problems-solving, conflict resolution, negotiating and networking skills, decision-making, work delegation and organization, and verbal/written communication skills.
13.5 Accurately documents all patient interactions in the electronic medical record.
13.6 Demonstrates self-directed learning needs and seeks ways to meet own professional development.
13.7 Applies professional nursing skills in the treatment of illness: Works independently to assess and evaluate understanding of disease process, treatment plan, and/or lifestyle changes; Facilitate interdisciplinary communication; Assess learning needs of patient and caregiver(s) to support the patient through the care continuum
BSN required. A bachelors degree in another field can be substituted if the incumbent has a masters degree in nursing.
3-5 years clinical experience in Care Coordination/Case Management required. Oncology experience strongly preferred. Evidence of essential leadership, advocacy, communication, education and counseling.
Current RN licensure in the State of Connecticut.
Core philosophy or values consistent with a patient-centered approach to care. Culturally effective capabilities demonstrating a sensitivity and responsiveness to varying cultural characteristics and beliefs. Demonstrates professional, appropriate, effective and tactful written, verbal, and nonverbal communication with patients, families, medical staff, colleagues, vendors, and other departments throughout the continuum of care to promote continuity of care and services and enhance clinical image.