Nurse Navigator - Pediatric Physical Medicine & Rehabilitation, Peds Ortho

Utilizes the nursing process for assessment, planning, implementation, and
evaluation to provide safe, therapeutic care. Functions as a member of the
interdisciplinary and nursing teams; carries out established nursing procedures
and performs related duties as required; performs nursing care for patients with
more complex needs with assistance and supervision. Assists with the management
of patient care administered by other members of the nursing team.

The Pediatric Physical Medicine and Rehabilitation (PM&R) Nurse Navigator and
Peds Ortho serves in a resource role and delivers direct patient care to
Pediatric PM&R and Peds Ortho population.  This clinician is experienced and
highly skilled with an in-depth knowledge and understanding of related
conditions and diagnoses, the major treatment modalities, symptom management,
supportive care, and patient education for PM & R and ortho in the pediatric
population. 

At this operational level, the nurse proactively embraces the Orthopaedic
Society/Standards of Orthopaedic Nursing practice to utilize the nursing process
for assessment, planning, implementation and evaluation to provide safe,
therapeutic care.  The nurse utilizes an interdisciplinary approach across the
continuum of care with adherence to National Patient Safety Goals set forth by
regulatory requirements. The nurse is recognized and utilized as a clinical
resource and demonstrates investment in the overall forward movement of the
unit/clinic and the organization. The nurse is responsible for bringing together
the multidisciplinary efforts of the Attendings, Advanced Health Practitioners,
Clinic Staff, Residents, Fellows, IP Nursing Staff, PT/OT, Case Management,
Pharmacy, Practice Coordinators, Analysts, and all other ancillary and support
departments to ensure a high quality, coordinated, and satisfying experience for
the patient. The Nurse Navigator will be involved with the department and Health
System quality metrics.

RESPONSIBILITIES

DUTIES & ESSENTIAL JOB FUNCTIONS

The Pediatric PM&R Nurse Navigator/Peds Ortho nurse is working as a member of
the multidisciplinary team, will:

* Coordinate all new patients by conducting phone intake, triaging according to
practice guidelines and appropriateness criteria (including communicating
these criteria to referring providers), and ensuring that all necessary
information is obtained prior to new patient appointments.

* Provide/coordinate ongoing care for established patients by performing
nursing assessments, managing patients’ overall care plan, providing nursing
interventions for disease/symptom management and interacting with third party
payors to provide rationale for proposed treatment plans. Will answer phone
calls and triage.

* Provide counseling regarding patients/families’ overall responses to
potential or actual health problems related to PM&R both in person or by
telephone.

* Act as a referral liaison with other services, departments, and external
services to assist in the coordination of care among multiple health care
providers and community agencies, and across healthcare settings, including
inpatient, post-acute care, and ambulatory settings.

* Develop more efficient procedures and policies to improve new and established
patient care flow, accessibility to services, and patient education including
symptom management and treatment resources.

* Develop and implement care management plans to improve patient health. This
will involve working closely with patients’ primary care physicians and other
health care providers.

* To enhance patient engagement and promote appropriate patient expectations
through implementation of shared decision-making tools, including decision
and communication aids.                 

%

of time

Essential Function (Yes/No)

Key Responsibilities

(To be completed by Supervisor)

20

Y

CLINICAL KNOWLEDGE/SKILLS MANAGEMENT

A. Clinical Knowledge

1. Assesses, plans, implements, and evaluates appropriate interventions for
Pediatric PM&R and Peds Ortho patients.
2. Integrates nursing theory, research, and knowledge of Pediatric PM&R and
Peds Ortho.
3. Maintains knowledge base consistent with the advances in treatment related
to Pediatric PM&R and Peds Ortho.

B. Clinical Skill

1. Performs priority technical procedures required by the practice assignment
and does so safely, legally, effectively, and efficiently.
2. Utilizes computer technology for, and maintains confidentiality of data
collection, documentation, communication and research. Proficient in Apex.
3. Assists in informed consent process, screening potential patients for
clinical trials, assurance of adherence to protocol inclusion and exclusion
criteria.
4. Performs casting and splinting activities.

C. Clinical Organization

1. Manages clinical situations with advanced skills, ensuring the
incorporations of patients/families’ physical, psychosocial, and cultural
needs.
2. Utilizes the nursing process in providing care for a group of patients in
accordance with all Medical Center and Ambulatory Services Policies and
Procedures.
3. Establishes and/or revise priorities for job/patient care activities based
on acuity, visit volume, resource availability, patient/family preference,
and scheduled procedures.
4. Seeks consultation, supervision, and/or assistance when unable to perform
procedures effectively, safely, or independently.

D. Patient Care Management

1. Functions as patient advocate and facilitate patient/family participation in
decisions regarding their care. Is a resource to patients and families.
2. Supervises patient care and delegates appropriate components in a manner
that promotes efficiency, teamwork and optimal patient care outcomes.
3. Evaluates and provides consistent and timely feedback to members of the
health care team and Practice Director regarding the quality of patient
care.
4.  

         care agencies

5. Functions as contact person to triage patient care requests and referrals to
clinic.
6. For hospitalized patients, follow the patient while hospitalized, escalate
long stay/high cost cases per format and communication process and actively
engage in potential disposition changes to assure an appropriate discharge.
7. For post index stay patients, provide timely ongoing contact and follow-up
with patient to ensure understanding of condition/clinical status,
procedure, plan of care, and need for follow-up care.
8. For post index stay patients, conduct ongoing contact and follow-up with
post-acute care providers and other providers on a timely basis and notify
providers or readmissions and significant clinical status changes as
appropriate.
9. Coordinates California Children’s Services (CCS)

20

Y

NURSING PROCESS/DOCUMENTATION

Meets Medical Center documentation standards as evidence by documentation of the
following:

A. Assessment

1. Screens and assesses patients for pain. Contributes to or participates in
pain management plan. Coordinates with IP staff, Pharmacy, APP’s.
2. Screens and assesses patients at risk for nutritional and functional
problems. Identifies and reports instances of dependent adult abuse/neglect,
and domestic violence in accordance with Medical Center policies.
3. Screens and assesses patients for complications. 

B. Planning

1. Prioritizes patient needs and helps patient formulate plan of care.
2. In response to data indicating potential or actual risk to individual’s
health, initiates action to correct, reduce or prevent the risk.
3. Assists members of health care team in the formulation and implementation of
the patient’s plan of care.
4. Provides and documents a rationale for actions or decisions based on
scientific principles, standards of nursing practice, previous experience,
and/or clinical judgment.

C. Implementing

1. Prepares patients for and instructs them about specific diagnostic and
therapeutic procedures and treatments.
2. Performs patient care procedures required by scope of clinical assignment
and in accordance with the Medical Center and Ambulatory Services policies
and procedures.
3. Responds and participates in the management of emergency clinical issues.
4. Administers medications safely.

D. Evaluating

1. Documents patient outcomes and responses to nursing interventions.
2. Utilizes theoretical knowledge and clinical skill to develop alternate
approaches to patient and family care.

E. Teaching

1. Identifies patient, family and/or patient’s caregiver learning needs and
potential barriers to learning and documents on teaching records or on flow
sheets.
2. Identifies patient, family and/or patient’s caregiver teaching interventions
specific to patient’s diagnosis and ability to learn, collaborating with
other disciplines as appropriate.
3. Involves patient, family, and/or the patient’s caregiver in teaching. 
4. Participates in the evaluation and revision of patient education materials.
5. Evaluates the patient, family and/or patient caregiver’s response to
teaching.

20

Y

COMMUNICATION

1. Responds to the emotional needs of patients, families and/or caregivers by
demonstrating a sensitivity to their sociocultural dynamics.
2. Interacts with patients, families, caregivers and staff in a supportive,
calm, and therapeutic manner.
3. Demonstrates courtesy, common sense and follow through in all telephone
communications, maintaining the telephone standards established be the
Medical Center.
4. Listens respectfully to the ideas, opinions and feelings of others.
5. Demonstrates sensitivity, respect, tact and diplomacy in all interactions.
6. Communicates and accepts constructive feedback in a manner that promotes a
positive outcome and supportive work environment.
7. Utilizes advanced interpersonal skills to facilitate problem resolution with
members of the health care team, patients and their families.
8. Utili