RN, Heart Failure Program Coordinator

Department Overview

The Heart Failure Nurse Coordinator is responsible for coordinating the comprehensive specialized care for patients within our Advanced Heart Failure Program, both in the inpatient and the outpatient setting. The coordinator collaborates with the health care team and provides leadership in achieving standards of care, including on-going quality and evidence-based practice to ensure process efficiencies.

This role also provides formal and informal program education within facilities as is relevant, and collaborates with facility administration, medical directors, nursing staff and community partners in order to assure process improvement for the care of the advanced heart failure patients. Through knowledge and experience, the Heart Failure Nurse Coordinator should have the skill set to coordinate and oversee the patient care of this high-risk patient population throughout the continuum and can organize and interpret trends in registry data points and focus on continually improving patient outcomes. The Heart Failure Nurse Coordinator can support professional knowledge and healthcare management through effective interactions and communications with clinicians, health care administrators, community agencies and other professionals.  

Function/Duties of Position

As an administrator, the Heart Failure Nurse Coordinator is responsible for overseeing internal staff education and competencies and for serving as a resource to all nursing areas for the care of this patient population.  

The Heart Failure Nurse Coordinator supports the Heart Failure program in delivering preventive, primary and acute healthcare services to adults with heart failure; provides education that aligns with standards and evidence based research,; contributes to new knowledge and/or technology by supporting  or participating in research; and, supports quality improvement efforts in the heart failure program through evidence-based practice, regulatory standards, national registry participation and service line activities.

Assure the safe, efficient, high quality and customer-oriented management of patient care to identified patient populations; provide health teaching with an emphasis on prevention of illness and health maintenance as needed to supplement the standard of care; and, perform care coordination for patients to  support them through their healthcare journey.

Performs education and coordination of care for high-risk patients as deemed appropriate (inpatient, and in clinics when appropriate). Collaborates with internal and external clinicians and agencies to coordinate transitions of care for patients with heart failure. Specifically provides the following: 

• Inpatient rounding and surveillance of patients admitted with heart failure diagnoses. 

• Provides individualized inpatient heart failure patient education for select patients (based on needs assessment and heart failure program definition) 

• Supports a patient-centered care plan in partnership with the care team.  

• Collaborates with care team to provide guideline directed heart failure care 

• Works with inpatient teams to optimize transitions of care from inpatient to outpatient 

• Enhances healthcare team/provider and patient communication in discharge planning and care transitions to reduce hospital readmissions among patients with heart failure 

• Supports inpatient teams in securing heart failure hospital follow up visits and timely referrals to heart failure specialist as appropriate  

• Completes hospital discharge follow up phone calls for patients admitted with heart failure 

• Demonstrates knowledge of social determinants of health and barriers to implementation of appropriate heart failure management in partnership with the care team. 

• Applies culturally sensitive methods when transitioning heart failure patients from inpatient to outpatient. 

• Understands risk factors and comorbidities and their contribution to heart failure. 

• Understands indications for advanced heart failure, palliative care and hospice referrals 
• Educates and supports patients with Advanced Care Planning as needed.  
• Provides support  for ambulatory HF  providers and nurses. 
• Recognizes the importance of health-related quality of life (HRQOL) in patients with HF (e.g. cognitive dysfunction, substance use disorder, depression, symptom burden, functional status). 
• Coordinates with other health professionals and community resources to optimize care. 
• Coordinates provider appropriate follow-up 
• Understands the mechanisms of action, pharmacologic features, and dosing of existing and new agents for treating and managing HF. 
• Understands drug-drug and drug-disease interactions. 
• Provides education  for HF patients and their families (e.g. diet/fluid intake, medications, self-management, self-monitoring, and weight). 
• Works with inpatient and outpatient interdisciplinary teams to evaluate physical conditioning, social determinants, cognitive function to optimize patient centered care plan. 
• Re-evaluates patient centered care plan. 
• Evaluates metrics and costs associated with above care and helps design optimal model of care for patients with HF. 
• Clinical coordination of HF patients through transitions of care. 

Required Qualifications

• Minimum of 3 years recent experience in cardiovascular setting, with 2 years of clinical practice in the care of patients with heart failure. * Primary focus in Heart Failure *     * Inpatient and outpatient experience preferred*                            
• BSN Graduates: Baccalaureate Degree in Nursing from a program accredited by Commission of Collegiate Nursing Education (CCNE), Accreditation Commission for Education in Nursing (ACEN) or Commission for Nursing Education Accreditation (CNEA) 30 days before start date.

• ADN Graduates: Associate Degree in Nursing from an accredited program 30 days before the start date.
• Associate degree Nurses required to enroll in BSN program within 3 years of hire and complete within 5 years of hire
• Current, unencumbered Oregon State Registered Nurse License
• Washington license within 6 months of hire
• BLS from AHA required. New hires will be enrolled and required to complete during orientation.
• Must be able to perform the essential functions of the position with or without accommodation

Preferred Qualifications

•  Progressive leadership experience and/or experience in process/quality improvement initiatives preferred 
• Heart Failure Certification (HF-Cert) or Certified Heart failure Nurse (CHFN) Preferred. Must be obtained within 3 years of hire)

Additional Details

Length of Orientation – Experienced Nurse

• External candidates: OHSU & Nursing New Employee Orientation (NEO) for about a week.
• Orientation experience for 3 days-26 weeks depending on the care area.

This position also comes with great benefits! Some highlights include:

• Comprehensive health care plans. Covered at 100% of the cost for full-time employees and 88% for dependents.
• $50K of term life insurance provided at no cost to the employee
• Two separate above market pension plans to choose from
• Vacation - 192 to 288 hours per year depending on length of service, prorated for part-time
• Holidays - up to 64 holiday hours per calendar year (employees accrue .0308 holiday hours for each hour paid – included in vacation accruals)
• Sick Leave - 96 hours per year, prorated for part-time
• Substantial public transportation discounts (Tri-met and C-Tran)
• Tuition Reimbursement
• Innovative Employee Assistance Program (EAP) including extensive wellness resources

Why apply to OHSU?