Stroke Nurse Navigator

Job Profile Summary

The Stroke Nurse Navigator (SNN) reports directly to the Stroke Advanced Practice Nurse, who works in close collaboration with the Director of the Comprehensive Stroke Center (CSC) and the Administrative Director of Neurology. The SNN serves as a point of contact for patients and families for the Comprehensive Stroke Center. The SNN works closely with a broad spectrum of healthcare providers, including the inpatient Neurology team, Stroke
and Emergency Consult Service, and the Stroke Advanced Practice Nurse, and
administrative personnel to ensure optimal transitions of care. The SNN will work as part of a multidisciplinary team to provide education and guidance to patients with stroke throughout the medical center. This clinical provider will provide patient care within regulations in accordance to their licensure within the Commonwealth of MA.

Job Description

ORGANIZATIONAL RELATIONSHIPS:
Develops and maintains relationships between all members of the CSC and Neurology Department, thus producing high performing, patient focused teamwork.

Duties and Responsibilities: The duties and responsibilities listedbelow are intended to describe the general nature of work and are not intended to be an all-inclusive list. Other duties and responsibilities may be assigned.

The SNN will perform daily rounds on inpatients with stroke as a primary diagnosis.

• The SNN will serve as a leader in patient stroke education, working with bedside nurses, therapists (PT, OT, SLP), and the Neurology team to provide stroke education to patients and/or families.
• The SNN, in conjunction with Case Management and social work, will assess caregiver readiness.
• The SNN will conduct post-discharge patient follow up phone calls, depending on the patient’s diagnosis and discharge disposition, including 7 day, 30 day, 60 day, 90 day, and 180 day calls.
• The SNN will assess patient’s knowledge of medications, follow up appointments, and stroke knowledge, providing additional education on an on-going basis after discharge.
• The SNN will participate in quality assurance initiatives with the Comprehensive Stroke Center, including, but not limited to review of hospital discharge summaries for medication reconciliation and outpatient appointments in order to improve transitions of care.
• The SNN will work with the Stroke Advanced Practice Nurse and Stroke Data Analyst on quality improvement projects within the Comprehensive Stroke Center with a focus on patient education initiatives.
• The SNN will participate in community outreach and education initiatives with the Director of the CSC, Stroke Advanced Practice Nurse, and Stroke Data Analyst.
• The SNN will provide support to stroke patients and their families, by leading a stroke support group.
• The SNN will maintain patient logs, such as Complex Stroke Follow up Phone Calls and 90 day mRS Phone Call logs in Excel.

Physical Requirements:

1. Prolonged, extensive, or considerable standing/walking.

2. Lifts, positions, pushes and/or transfer patients and equipment.

3. Considerable reaching, stooping, bending, kneeling, crouching.

4. Frequent exposure to hazardous chemicals, sick patients, bodily substances, noise and possible exposure to radiation, lasers, electric shock, etc.

5. Regularly exposed to the risk of bloodborne diseases and other transmissible infections.

6. Contact with patients under wide variety of circumstances.

7. Subject to varying and unpredictable situations.

8. Handle emergency and crisis situations.

9. Subjected to irregular hours.

10. May have contact with hazardous materials.

Skills & Abilities:

1. Ability to effectively communicate with patients, families, physicians, and healthcare team.

2. Knowledge and application of the nursing process to implement a nursing plan of care.

3. Possesses and applies the skills and knowledge necessary to provide care to patients throughout the life span, with consideration of aging processes, human development stages and cultural patterns in each step of the care process.

3. Skills and knowledge to provide care to the age groups of the population served including:Knowledge of growth and development; Ability to interpret age specific data and response to care; and Provide age appropriate communication

4. Possessthe maturity, self-confidence, and ability to follow complex patient management plans in collaboration with medical staff.

5. Ability to provide primary care for a caseload of patients according to practice guidelines and hospital policies, procedures and protocols.