Coordinates with physicians, staff, and non-Kaiser providers and facilities regarding patient transferring to Kaiser or patients admitted to non-Kaiser facilities. In conjunction with physicians, obtains report from outside facilities regarding Kaiser members awaiting or anticipating transfer back to Kaiser Moanalua Medical Center. Monitors all clinical activities, able to identify possible levels of care (ED to ED transfer, direct admit to observation or inpatient, inpatient to inpatient transfer), and obtains all pertinent clinical information needed for transfer or for updates of patient clinical status. Works in conjunction with Hospital Operations Coordinator to problem solve, identify trends, and report barriers to patient throughput.

• Intakes calls from outside Facilities (and other entities such as AMR, EMS) regarding patients who may need to be admitted or transferred. In consultation with physician, determine appropriate disposition of patient. Documents relevant patient information in KPHC and logs as appropriate.
• Provides support to physicians in Call Center to ensure timely and well-coordinated care, using clinical skills to collect and report all pertinent medical information pertaining to the patients status and care. Identify needs for the continuum care (acute, chronic or follow-up) and additional medical records in order to report comprehensive information to Call Center physicians. Articulate and understand medical information and history through documentation and verbal report within scope of practice.
• Manages the admission and transfer of patients in facilities outside of Kaiser Moanalua Medical Center (Non-Kaiser facilities, Kaiser Clinics, Outer Island facilities), while providing a timely and considerate duty of care to those patients. Provide comprehensive follow up to the referring facilities.
• As appropriate, arranges for follow-up care. This includes primary care appointments, specialty referrals, and referrals for continuing care services.
• Proactively reviews alerts of patients in outside EDs, documents information, and contacts EDs as appropriate.
• Process and document patient information, with respect to all guidelines and policies in place including regulatory knowledge of EMTALA, Kaisers Principals of Responsibility, Compliance policies, and quality initiatives.
• Participates and/or leads in the creation and building of RN protocols and support staff workflows to establish standardization and maintenance of practice standards with the knowledge of regulatory requirements (i.e. RN scope of practice, EMTALA, CMS).
• Acts as a liaison across many points of communication within Kaiser Permanente Hawaii from physicians to nurses, as well as departments and non-Kaiser facilities.
• Participates in utilization review process for patients in outside hospitals. Supports patient care coordinators in repatriation of patients in outside hospitals.
• Monitors care processes and participates in the development and implementation of guidelines, pre- printed physician orders, care paths, etc. for patient care. Identifies and assists in the implementation of opportunities for cost-savings and improvements in the quality of care across the continuum. Establishes and maintains effective relationships between Kaiser Permanente and community facilities. Identifies quality improvement and relationship building opportunities. Monitors cases and reports findings to Hospital Administration, Director of Emergency Services & Hospital Operations, and Executive sponsors for outside services projects.
• May perform patient care to the extent necessary to maintain clinical expertise, competency, and licensing necessary to fulfill job responsibilities and to direct the provision of care on the unit.
• Provides direct patient care on an as needed basis. Provides services that are within scope of license and in compliance with all legal, regulatory, and policy requirements relevant to clinical role performed.
• Incorporates the KP Nursing Vision, Model and Values throughout their Nursing Practice.
• Maintains confidentiality as required by HIPAA and compliance of KP Principles of Responsibility with access and recording of KP proprietary records (i.e. patient data, performance data, project-specific data).