We are so glad you are interested in joining Sutter Health!
Organization
SMPMC-Sutter Mills Peninsula Medical Center
Position Overview
Provides advanced clinical management for medically complex patients participating in the Multidisciplinary Transition Support Program (MTSP), supporting safe, coordinated transitions from hospitalization to longitudinal care in collaboration with the supervising physician.
Performs comprehensive transition-focused clinical assessments, develops and directs individualized transition support plans, and provides medication management, patient and caregiver education, care coordination, and ongoing clinical reassessment to optimize continuity of care and patient outcomes.
Collaborates with physicians and the interdisciplinary team to facilitate safe transitions across the healthcare continuum.
Participates in program development, quality improvement, and evaluation of the MTSP.
Practices in accordance with organizational policies, evidence-based practice, the California Nurse Practice Act, and approved standardized procedures.
Job Description
Job accountabilities
Performs comprehensive transition-focused clinical assessments and develops, implements, and directs individualized transition support plans for patients participating in the Multidisciplinary Transitional Support Program (MTSP).
Provides advanced clinical management across the continuum of care to support safe, coordinated transitions from hospitalization to the patient's longitudinal care team in collaboration with the supervising physician.
Monitors patient progress, performs ongoing clinical reassessment, modifies the plan of care as clinically indicated, and facilitates timely escalation of care.
Performs medication reconciliation, optimizes medication management, and provides patient and caregiver education to support safe transitions of care.
Collaborates with physicians and the interdisciplinary team to coordinate care across the healthcare continuum.
Identifies clinical, psychosocial, and social barriers to recovery and facilitates appropriate interventions and community resources.
Documents assessments, interventions, care plans, and patient outcomes accurately in the electronic health record.
