1. Ensures timely communication with patients, significant others, and other health
care providers through professional collaboration.
Ensures open communication with patient and significant others.
Discusses referrals with physician when appropriate.
Participates in community education and outreach programs related to Florida Hospital Community Care.(FHCC)
2. Collaborates with other health care providers to deliver patient-centered care coordination in a manner consistent with safe, efficient and cost-effective resource utilization.
Coordinates with other disciplines and community resources.
Discusses progress of patients with other members of FHCC team.
Works collaboratively with the FHCC team to integrate service delivery system for co-
Works in collaboration with FHCC, subsidiaries, and external collaborating
agencies/groups to develop a system of continuity of care.
3. Plans, implements and documents patient visits.
Documentation on chart is timely and appropriate.
Develops educational materials as necessary for use with patients and families.
4. Assists with community outreach educational programs related to care coordination
Assists with development and distribution of educational materials as necessary for use
in community programs.
Assists with the assessment of needs, development and presentation of community medical and
Collaborate with FHMMC Education Department on accreditation of trainings for
professional continuing educational credits and for the marketing, registration, and
presentation of psycho-educational trainings.
5. Complete direct patient care coordination with the Community Care and Transitional Care Programs
Provide support to the region providing direct patient care coordination when needed at other locations within the region
Assist with direct patient care coordination when CCN/TCC team members are on PDO, FMLA, etc.
Follow identified high-risk Medicare TCC patients for 30-days post-discharge
Other duties as assigned
1. Provides patient assessment for medical and behavioral needs.
Physical, psychological and emotional outcomes are individualized and identified.
2. Formulates a plan of care based on assessment, diagnosis, age, SEMAP and patient profile.
Systematic and pertinent collection of data for each patient.
The plan of care is consistent with safe, effective patient care and age.
The urgency of medical, psychological, social and emotional needs is determined, and the
course of action is formulated to attain expected outcomes.
3. Collaborates a plan of care based on assessment, diagnosis, age, SEMAP and patient
Interventions are based on patient need and consideration of patient and/or
4. Evaluates and modifies plan of care based on patient responses and attainment of expected
The patient’s response to the intervention is regularly evaluated to determine progress
toward resolution of needs.
Conducts a medication reconciliation as part of the patient evaluation/re-evaluation process.
5. Adheres to established standards of practice including activities and behavior that
characterize professional status.
Is accountable for his/her actions.
6. Is aware of and adheres to hospital policies and procedures.
Demonstrates adherence to respective policies and procedures.
7. Functions as core member of FHCC team.
Provides leadership for other team members.
Organizes program materials, content, schedule.
Assists FHCC team in efforts to promote care coordination.
Evaluates comprehension of information presented.
8. Other duties as assigned.
What You Will Need:
Florida RN License required.
A minimum of BSN or BA education or minimum of 3 to 5 years of healthcare experience.
Driver’s license required.
Florida RN licensure.
Basic Life Support
Provide patient behavioral and medical assessment; eliminate care gaps; work with the core Community Care team and partners such as physicians, pharmacies, home health care, hospice, skilled nursing facilities, inpatient rehabilitation facilities, and universities. This program is comprised of high user patients in our community.
At AdventHealth, Extending the Healing Ministry of Christ is our mission. It calls us to be His hands and feet in helping people feel whole. Our story is one of hope — one that strives to heal and restore the body, mind and spirit. Our more than 80,000 skilled and compassionate caregivers in hospitals, physician practices, outpatient clinics, urgent care centers, skilled nursing facilities, home health agencies and hospice centers are committed to providing individualized, wholistic care.