Responsibilities The Patient Navigator's primary function is to guide patients through the health care system by assisting with access to care issues, developing relationships with service providers, tracking interventions, tracking outcomes and follow-up. Educates patients and families on diagnosis and recommended treatment options throughout the continuum of care including surgical interventions, procedures, ancillary tests, and post discharge follow up.
Role responsiblities include but not limited to: Provide post-discharge care coordination through 7-day and 90-day follow-up calls, including review of discharge instructions, confirmation of follow-up appointments, and completion of the modified Rankin Scale (mRS) assessment. Provide patient and family education regarding stroke diagnosis, treatment plans, secondary prevention strategies, and medication management as needed.
Assess adherence to secondary stroke prevention therapies, verify medications, monitor for medication-related side effects, and screen for emotional and mental health concerns. Facilitate scheduling of outpatient diagnostic testing, specialty referrals, and follow-up appointments as needed. Serve as a patient and family advocate, helping navigate the continuum of stroke care and access appropriate resources.
Connect patients and families with community resources, stroke support groups, educational programs, and other services that support recovery and long-term wellness. Identify social determinants of health, financial barriers, and community resource needs, and coordinate appropriate referrals and support services. Collaborate with the interdisciplinary care team to escalate unresolved clinical concerns and ensure timely physician follow-up when indicated.
Participate in community outreach initiatives, stroke awareness activities, health fairs, screenings, support groups, and educational events as requested to promote stroke prevention, recognition, and recovery. SCRN or CNRN Certification preferred* Qualifications Required: Three years nursing in acute care setting Bachelor Degree Registered Nurse