Nurse- Lung Transplant BWH

Job Summary

The Lung Transplant Nurse Coordinator is a professional registered nurse licensed in the state of Massachusetts with transplant experience who is responsible for all aspects of ambulatory and in-hospital care of the pre-transplant, inpatient and post-transplant patient. This position focuses on the pre-transplant patient and works closely with all members of the transplant team, inpatient staff, and others to ensure efficacious care during the transition between pre-, peri-, and post-transplant phases.

Principal Duties and Responsibilities

• Reviews referral documentation and medical records and meets with Program Directors to identify potential transplant patients; contacts referring physician practices and coordinates pre-transplant evaluation with primary care providers.
• Collaborates with all members of the transplant team for seamless coordination of newly referred patients for lung transplant evaluation.
• Coordinates and facilitates New Patient and Pre-Transplant clinic sessions and ensures completion of necessary testing at appropriate stages of evaluation.
• Participates in the longitudinal informed consent process with patients in the consultative and evaluative phases of lung transplantation.
• Facilitates completion of the evaluation for lung transplant candidacy and ensures multi-disciplinary participation per protocols and policies.
• Compiles and summarizes evaluation results for presentation at multidisciplinary team meeting utilizing Epic and regulatory databases.
• Facilitates and coordinates educational programs for patients in the consultative and evaluative phases of transplant.
• Works closely with the Pre-Transplant Administrative Coordinator to facilitate care of patients in the consultative, evaluative, and wait list phases.
• Works with financial coordinator to provide medical information as requested by third party payers.
• Communicates patient information to the care team via appropriate documentation and team conferences.
• Conducts post acute patient follow-up to ensure execution of follow-up care and quality of care.
• Manages and continually improves systems to provide information on patients' current level of care/changes in clinical status to the Lung Transplant Team, referring physicians, financial coordinator/third party payers, UNOS and others.
• Works with Physician Directors to review, revise, and initiate changes to improve the pre-transplant management process.
• Participates in multidisciplinary patient care conference and medical management meetings.
• Assists with preparation of reports/data for utilization of services review, QM activities, UNOS and Center of Excellence contracts.
• Participates with all assigned QAPI processes and e-care improvement initiatives.
• Coordinates out-patient care of pre lung transplant patients, including participation in multidisciplinary rounds, documentation of assessment and plan in the medical record, organizational efficiency and discharge planning and follow-up.
• Facilitates interactions of the multidisciplinary team members, including physicians, social work, transplant pharmacist, nutritionist and outside consultants.
• Acts as a liaison between members of the inpatient care team and outpatient management team, including lung transplant nurse practitioners.
• Communicates with referring physician team to keep them up-to-date regarding patients' clinical status.
• Telephone contact with patients to assess clinical status, monitor response to therapy, adjust medications in consultation with clinical providers, and organize outpatient or inpatient follow-up as needed.
• Assists in urgent patient triage, including emergency room visits and transfer from outside institutions, and documents care provided.
• Provides education to transplant patients and family members regarding important aspects of care.
• Sets up consults with specialty providers, follows up consult recommendations and communicates results to patient and other providers.
• Assists with communication and correspondence to/from patients, employers, pharmacies and insurance providers.
• Meets regularly with medical program director and nurse practitioners to facilitate quality and process improvement initiatives.
• Attends weekly clinical meetings and lung transplant clinics as needed.
• Works with financial counselor and social work to assist patients/families in need of financial support, insurance coverage, medications, housing and/or utilities.
• Cross trains to assist in covering for the in-patient nurse coordinator and post-lung transplant nurse coordinators.
• Collects demographic and clinical data from hospital computer system, administrative sources, charts and weekly conferences and enters data into transplant databases as needed, including the United Network for Organ Sharing (UNOS) system.
• Provides research nurses with clinical data on subjects enrolled in research studies.

Qualifications

• Graduate of an approved school of nursing with current registration in Massachusetts required.
• BSN required.
• One year or more of prior experience (recent within 2 years) in the care of pulmonary, thoracic surgery or lung transplant patients required.
• Prior experience with Lung Transplant patients strongly preferred.
• Prior Transplant Coordinator (1 year or more within the last 5 years) experience strongly preferred.
• Ambulatory experience (current defined as within the last 12 months) with telephone triage strongly preferred.
• Knowledge of community resources and post/non-acute care providers preferred.
• ABTC Certified Clinical Transplant Coordinator preferred.
• Active membership in a related professional organization is recommended.

Skills and Abilities

Ability to work independently while collaborating with others in the care of complex patients with advanced lung disease, multiple co-morbidities, and eventual lung transplantation. Excellent written and oral communication skills to work with individuals from various fields of expertise. Flexibility, excellent judgment, and the ability to work independently and as part of a team are essential. Excellent organizational abilities to formulate and meet rigorous clinical timetables. Must display interpersonal skills and ability to work as part of a multidisciplinary team.