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Care Transition Nurse

Company

Summit Health

Location

Hartford, United States

Type

Full time

Description

Position Summary

The Care Transition Nurse (RN) coordinates and manages patient care transitions across healthcare settings, including hospital discharge to home, rehabilitation, or skilled nursing facilities. The role focuses on improving continuity of care, reducing hospital readmissions, and ensuring patients and caregivers understand discharge instructions, medications, and follow-up care plans.

Key Responsibilities

  • Coordinate safe patient transitions from hospital to home or post-acute care facilities.
  • Conduct comprehensive patient assessments prior to discharge.
  • Provide education to patients and caregivers on disease management, medications, and care plans.
  • Perform medication reconciliation to ensure accuracy and patient understanding.
  • Schedule and confirm follow-up appointments with primary care providers or specialists.
  • Collaborate with physic...
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