The Patient Care Facilitator is accountable for care
coordination from admission to discharge for a group of patients on
an assigned nursing unit. For each assigned patient, the PCF
functions in concert with the interdisciplinary care team and
physicians to ensure the development and implementation of an
individualized plan of care, daily (or more frequent) review and
revision of the plan of care based on patient progress, and ongoing
communication with the patient and family regarding expected
outcomes of care. The PCF is accountable for identifying and
removing barriers that will prevent and/or delay a patient from
reaching his/her outcome goals in a timely manner and for the
development and execution of an appropriate discharge plan to
address the patient’s post-acute care needs. The PCF supports the
collection and analysis of data related to patient outcomes and the
effective use and access to resources to support patient outcomes.
In partnership with the Unit Nurse Manager, the PCF shares ongoing
responsibility for the outcomes of care for patients throughout
their stay on a designated unit
BSN required. Master’s degree in nursing preferred.
Current RN licensure in the State of Illinois and CPR
Minimum of 2 years of recent acute care nursing experience.
Active participation in unit/patient performance improvement
Understanding of the principles of performance improvement, care
coordination, care transitions, discharge planning, and utilization
Excellent communication, collaboration, and conflict management
Evidence of continuing professional development.
Leads efforts with the interdisciplinary care team to develop,
implement, and evaluate an individualized plan of care to achieve
optimal patient outcomes for each assigned patient.
Ensures that patient safety risks are assessed and prevention
measures are implemented and communicated to all members of the
interdisciplinary care team.
Routinely reviews the plan of care with the patient and family
to assist them in understanding goals of care and movement toward
Assures timely communication of patient’s response to care,
clinical data, and diagnostic test results to appropriate
physicians, care team members, and patient/family.
Ensures patient education needs are being met on a regular
Makes referrals to other disciplines as necessary to meet
patient care needs (social work, therapy, etc.).
Conducts daily “huddles” with care team to ensure plan of care
is being implemented and progress toward established goals is being
Provides timely communication of changes in the plan of care to
all care team members and patient/family.
Leads patient/family care conferences on appropriate patients
based on LOS and complexity of care.
Collaborates with physicians and Utilization Management staff to
ensure resource utilization remains within covered benefits.
Monitors each patient’s treatment plan for testing/treatment not
related to current hospitalization and interfaces with physician to
identify alternatives to address needs.
Writes plan for post-discharge services and collaborates with
Discharge Specialist to ensure services are scheduled with
appropriate entities, which could include home health, home
infusion, hospice care, durable medical equipment, medical
supplies, and outpatient services.
Ensures appropriate discharge education is provided to
Interacts with patient/family/caregiver to ensure discharge plan
meets patient needs.
Collaborates with Discharge Specialist to update patient/family
and interdisciplinary care team of changes in the discharge
Ensures care provided to assigned patients is consistent with
national quality guidelines and appropriately documented in the
patient’s medical record.
Identifies problems and/or opportunities for improvement in
clinical outcomes, patient safety, and/or resource utilization.
Leads efforts to resolve ongoing patient and/or systems
Participates in unit goal setting, program development, clinical
and system process improvement, and achievement of desired unit
Implements strategies to reduce resource utilization and length
of stay for assigned patients.
Assists with collection, analysis, and reporting of clinical
outcome and resource utilization data.
Participates in local and national professional nursing
Identifies areas for professional growth and demonstrates
ongoing activities necessary to meet professional goals and
changing needs of organization.
Promotes implementation of evidence-based nursing practice.
Participates in nursing scholarship and research activities.
Partners with Unit Nurse Manager to ensure unit clinical outcome
goals are achieved.
Adheres to Statement of Values and Behavioral Standards.
One of the leading healthcare organizations in Illinois,
Memorial Health System of Springfield is a community-based,
not-for-profit corporation dedicated to patient care, education and
Our more than 6,700 staff members, partnering physicians and
hundreds of volunteers are dedicated to improving the health of the
communities we have served since 1897. In a year, we serve an
average of more than 40,000 inpatients, more than 667,000
outpatients and more than 125,000 patients in our four Emergency
Departments. Our highly skilled team has a passion for excellence
and is dedicated to providing a great patient experience for every
patient every time.
In support of our commitment to community responsibility, all
Memorial Health System affiliates participate in health screenings
and educational events to further provide for the healthcare needs
of our community. Learn more about our community
To improve the health of the people and communities we
To be the health system people choose over all others.
We put safety first.
We speak up, without fear, on matters of patient and colleague
We take action to create an environment of zero harm.
We respect others and show compassion.
We behave honestly and ethically.
We are accountable for our attitude, actions and health.
We advance our knowledge and skills.
We seek continuous improvement.
We deliver evidence-based care that leads to excellence in
We use resources wisely and maintain financial stability.
We work together to coordinate care and services across the
We promote healthier communities.