Nurse Coordinator Smilow Waterford - Yale New Haven Health

To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values - integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day.



EEO/AA/Disability/Veteran

1. Clinical Practice: Patient/Family Assessment (Initial and Ongoing)
1 .1 Collects Level II* patient data for new patients using established assessment form prior to initial visit
to assess patient/family current and projected future needs; Note: Level II patient data includes
physical and psychosocial history, current medical status, medication review, teaching/learning
evaluation
1 .2 Analyzes data compiled by the Intake Assistant to confirm completeness /accuracy and to determine
appropriate provider and/or provider visit sequence; identifies and communicates gaps to ensure that all
required data is available prior to initial consultative visit.
1 .3 Evaluates patient/family response to medical, nursing and supportive care interventions at regular
intervals (eg, following initial consultative visit, proposed treatment plan, initiation or modification of
therapeutic plan)
1 .4 Communicates initial and significant follow-up assessment findings to appropriate team members and
documents according to policy.

2. Clinical Practice: Patient/Family Education
2 .1 Develops a patient/family education plan based on assessment findings relevant to teaching learning
topics, styles and the identification of special needs and preferences.
2 .2 Provides patient/family instruction related to disease, treatment, potential adverse effects, symptom self
identification and management, parameters for distinguishing between what can be self managed and
what requires disease team intervention, how to contact the team.
2 .3 Provides selected handout materials to patients/families to reinforce verbal instruction

2 .4 Makes follow-up contacts (eg, by phone, email and visit) to ensure patient/family understanding of the
plan of care, evaluate adherence levels and reinforce education provided
2 .5 Documents patient/family response to information provided and communicates to the appropriate team
members.
2 .6 Coaches patient/family through diagnostic and therapeutic experiences to minimize anxiety and ensure
adherence to medical plan; provides warm handoffs at various points but maintains contact with
patient/family and point of care managers as patients move along the continuum.

3. Clinical Practice: Care Coordination and Patient/Family Referral
3 .1 Alerts Tumor Board Coordinator to place patient on listing for treatment planning session and , if patient
will be present, facilitates patient participation; attends treatment planning sessions and documents
treatment plans formulated.
3 .2 Interfaces with physicians, mid-levels, Practice Nurse and schedulers to ensure appropriate scheduling
of laboratory and diagnostic studies, procedures, therapeutic interventions following initial consultative
visit.
3 .3 Uses findings of assessment data, team-based interactions and established triggers to initiate referrals
for supportive care (eg, social work, nutrition, rehabilitation, psychological services) and community
agency assistance (eg, home care, support groups, etc). Monitors and reports response to consultative
intervention(s).
3 .4 Liaises among and between point of care coordinators and supportive care clinicians (eg, Patient
Service Managers, Clinical Care Managers, Social Work, etc) across care settings to ensure familiarity
with patient case and special needs; ensures that patient safety needs are met during handoffs to point
of care staff (eg, infusion, surgery, therapeutic radiation)
3 .5 Participates in patient/family treatment planning conferences with MD as requested by patient and/or
physician; accompanies patient/family to medical visits, interventional visits as desired by patient and
as schedule permits.

3 .6Anticipates and/or identifies potential logistical, financial, personal barriers to patient adherence to visit
schedule and therapeutic plan; makes other team members aware and interfaces with family members
and any relevant internal and external providers to troubleshoot/develop a plan to minimize or eliminate
obstacles.

4. Clinical Practice: Clinical Research
4 .1 Identifies candidates for open clinical trials and communicates to physician, mid-level provider and
assigned research nurse; collaborates with Research Nurses to ensure follow-through on clinical trials
accrual of individual patients.
4 .2 Anticipates and/or identifies potential logistical, financial, personal barriers to patient adherence to visit
schedule and therapeutic plan as per protocol; makes other team members aware and interfaces with
family members and any relevant internal and external providers to troubleshoot/develop a plan to
minimize or eliminate obstacles.

5. Clinical Program Support

5.1 Oversees Intake Assistant performance by analyzing accuracy and completeness of data compiled on
new patients and observing patient/family interactions; provides feedback to supervisor.
5 .2 Participates in the development/revision of scripting for Administrative Staff (Intake Assistant, Clinical
Secretary and Receptionists.
5 .3 Collaborates with other team members to develop and implement clinical tools relevant to new patient
access and navigation; evaluates tool effectiveness and reports to team.
5 .4 Identifies and monitors program quality metrics relevant to patient access and navigation services;
evaluates role effectiveness and reports to team.
5 .5 Participates in team-specific Patient Safety and Quality monitoring and performance improvement
action plans.
5 .6 Serves as an ambassador for the assigned Disease Team, representing the team and its unique
features to internal and external communities.
5 .7 Participates in community outreach programming (eg, public education forums, support groups, health
fairs, etc) as appropriate to disease team marketing and strategic plan.
5 .8 Reviews/provides content relevant to role and patient access for inclusion in staff scripting , website and
print materials for distribution.
5.9 Role models service excellence behaviors, incorporates disease team strategic plan elements into
clinical program development activities.

6. Professional Development
6 .1 Sets and strives to meet annual goals for professional development
6 .2 Achieves/maintains oncology nursing certification
6 .3 Actively participates in hospital and disease team committees and projects
7. Addendum: When needed or as assigned, performs practice/clinic nurse function as outlined in Clinical
Nurse in the Ambulatory Practice/Outpatient Multispecialty Care Center functional description/overview

EDUCATION (number of years and type required to perform the position duties):
Bachelors Degree in Nursing highly preferred; Masters Degree in Health-related field preferred

EXPERIENCE (number of years and type required to meet an acceptable level of performance):
A minimum of three (3) years experience in adult inpatient services, ambulatory oncology service or operating room .
Oncology experience preferred

SPECIAL SKILLS:
Connecticut RN license; Oncology Nursing Society certification (OCN, AOCN) desirable

ACCOUNTABILITY (how this position is held accountable for such as goals achievement, budget adherence, or
other areas of accountability):
Position is held accountable for collaboration and consultation, education, clinical practice, and research through
yearly written evaluations.

COMPLEXITY (describe planning, problem solving, decision making, creative activity, or other special factors
inherent in the responsibilities of this position):
In personal and job-related decisions and actions, consistently demonstrates the values of integrity (doing the right
thing), patient-centered (putting patients and families first), respect (valuing all people and embracing all differences),
accountability (being responsible and taking action), and compassion (being empathetic).

LICENSURE/CERTIFICATION:
Connecticut RN license;

2 years acute care rn, 2 years oncology rn experience required