Orthopedic Care Navigator
Steward Health Care is the largest private, tax-paying physician-led health care network in the United States. Headquartered in Dallas, Texas, Steward operates 35 hospitals in the United States and the country of Malta that regularly receive top awards for quality and safety. The company employs approximately 42,000 health care professionals. The Steward network includes multiple urgent care centers and skilled nursing facilities, substantial behavioral health services, over 7,900 beds under management, and approximately 2.2 million full risk covered lives through the company's managed care and health insurance services.
Steward Medical Group (SMG), Inc. is Steward's multi-specialty group practice with over 4,500 employees including over 1,800 physicians and advanced practitioners. SMG operates approximately 450 practice locations throughout Massachusetts, Southern New Hampshire, Rhode Island, Pennsylvania, Ohio, Florida, Utah, Arizona, Texas, Louisiana and Arkansas, and provides more than 4 million patient encounters per year.
The Orthopedic Care Navigator department serves as the primary program contact for patients, providers and other caregivers and is responsible for the overall effectiveness of patient care coordination.
The Orthopedic Care Navigator guides orthopedic patients throughout the entire continuum of care, from office visit to surgical procedure, discharge to home/Skilled Nursing Facility (SNF), and provides follow-up/guidance throughout the post-discharge phase. The Orthopedic Care Navigator facilitates consistent implementation of procedures, patient safety, quality, and effective transitions through preoperative, intraoperative, and postoperative phases of care; assists in streamlining the services, designing, implementing, and evaluating care, treatment, and services; enhances the patient/family experience, appropriately decreases the patient LOS and improves patient outcomes. works closely with orthopedic practice managers, surgeons, home health agencies, SNFs, and community programs to effectively coordinate the plan of care prior to the day of surgery and beyond discharge.
Care Continuum Facilitation
- Develops and maintains cooperative relationships with relevant members of the health care team.
- Coordinates, supports, and provides guidance for the orthopedic patient and family throughout all phases of care.
- Serves as an advocate for the patient during the development and implementation of the plan of care.
- Rounds on all orthopedic patients as needed post-operatively to enhance patient satisfaction and ensure quality of care.
- Appropriately shares information with relevant practitioners and/or health care organizations about the patient’s disease or condition across the continuum of care.
- Provides appropriate communication to relevant practitioners and/or health care organizations regarding changes in the patient condition and transitions in care.
- Reviews the medical record to ensure inclusion of appropriate information in order to support coordination of care and the transfer of information between the sending and receiving organization.
- In preparation for discharge, discusses and plans with the patient, family, practitioners and support services the care, treatment, and services that are needed in order to achieve the mutually agreed upon self-management plan and goals.
- Engages patients and their families during Joint camp.
- Collects and analyzes data to determine variance from the clinical practice guidelines.
- Maintains accurate and confidential records documenting numbers of patients served, services provided and unmet needs.
- Assists in the collection of relevant data from patients, relevant practitioners and other healthcare organizations/sources.
- Involves the interdisciplinary team and other practitioners across disciplines and/or settings in performance improvement planning and activities.
- Collects data to identify opportunities for performance improvement and analyzes performance measurement data to identify opportunities for performance improvement.
- Collects data to evaluate processes and outcomes internally trended over time and compared to an external data source for comparative purposes.
- Monitors and reports to leadership the indicators and incidents throughout the episode of care related to complications, patient self-management, patient education, patient experience of care and patient goal achievement.
- Appropriately assesses the patient’s physical and psychological status as needed.
- Documents and reports to the appropriate staff any physical or psychological changes that may have occurred with the patient.
- Effectively communicates the patient’s status throughout the continuum of care.
- Effectively understands and can respond to the needs of the patient and family members.
- Is appropriate and empathetic to patients and family’s needs, providing information and discussion when appropriate while considering the specific age of the patient and their families.
- Always maintains patient dignity.
- Differentiates between different age groups appropriately and provides excellent care to the specific age groups accordingly and in respect to their psychological and physical needs.
- Assists with the implementation and delivery of the patient’s plan of care, and evaluate outcomes as needed.
- Makes sound nursing judgments and seeks guidance from physician or other nursing resources appropriately.
- Competently cares for all age levels demonstrating the ability to assess and provide appropriate nursing care which meets the physical, psychological, social and spiritual needs of the patient.
- Complies with hospital policies and procedures, infection control policies and departmental standards of care.
- Evaluates patient’s outcome and reports changes to physician appropriately.
- Meets all required licensing continuing education and remains in good standing with licensing organization(s).
- Serves as a role model, and resource for all other nursing and technical staff, by sharing knowledge.
- Assists with the coordination of departmental in-services and its documentation.
- Maintains own specific certifications and competencies as required.
- Consistently maintains work schedule and attendance requirements as stated in the Medical Center's policies.
- Maintains patient confidentiality in accordance with HIPAA regulations.
- Maintains security of patient records.
- Assumes other necessary duties as assigned by Director, as needed.
Required Knowledge and Skills
Excellent verbal and written communications, as well as listening skills. Ability to prioritize workload, handle multiple tasks, and to work independently with limited supervision. Detail oriented and focused. Strives for high quality performance and takes initiative to make improvements and implement creative solutions. Ability to work in a team environment and to develop and maintain collaborative relationships with patients and their families and all members of the healthcare team.
Minimum Education Requirements
- Graduate of an accredited school of nursing
Experience in Orthopedics is required. Must demonstrate excellent organizational and multi-tasking skills. Must demonstrate professionalism and possess the skill, knowledge, and ability to interact collaboratively with healthcare teams. Demonstrates innovation, expert problem-solving skills and is self-motivated.
MA Nursing License. Orthopedic Nursing Certification (ONC) preferred.
Strong computer proficiency required, including Microsoft Office products, Databases, Internet, hospital information/patient care systems, email, telephone, paging, and fax.
Steward Health Care is an Equal Employment Opportunity (EEO) employer, Steward Health Care does not discriminate on the grounds of race, color, religion, sex, national origin, age, disability, veteran status, sexual orientation, gender identity, and or expression or any other non-job-related characteristic.
Steward Medical Group is taking additional necessary preparations to ensure patients can receive compassionate care in safe, carefully managed environment – with confidence and without fear.
Our Safe and Ready program consists of a rigorous [three-point] standard ensuring patient safety, confidence and convenience.
- Any COVID-19 related care takes place in designated areas away from other patients and their families.
- A stringent cleaning policy has been implemented throughout our facilities.
- A strictly controlled visitor and mask policy is required for patient and colleague safety.