Patient Care Facilitator
Company: Memorial Health
Posted on: September 15, 2021
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
- Active participation in unit/patient performance improvement
- Understanding of the principles of performance improvement,
care coordination, care transitions, discharge planning, and
- 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
- 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
- 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
- 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
- Participates in nursing scholarship and research
- Partners with Unit Nurse Manager to ensure unit clinical
outcome goals are achieved.
- Adheres to Statement of Values and Behavioral Standards.
Performs other related work as required or
The intent of this job description is to provide a representative
summary of the major duties and responsibilities performed by
incumbents of this job. Incumbents may be requested to perform
tasks other than those specifically presented in this
Keywords: Memorial Health, Springfield , Patient Care Facilitator, Other , Springfield, Illinois
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