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RN/Transitional Care Nurse- Quality/Care Coord.-Med Center

Category:  Registered Nurse
Department:  Care Coordination/Quality Resources
Status:  Full Time


The Transitional Care Model is designed to prevent health complications and re-hospitalizations of chronically ill and elderly hospital patients by providing them with comprehensive discharge planning and home follow-up.


At the time of hospitalization, each patient is assigned a LACE score used to identify patients at risk for readmission. The Transitional Care Nurse will then perform an intense assessment on high risk patients that includes health status, health behaviors and level of social support. The Nurse will then establish an individualized plan of care consistent with evidence-based guidelines, in collaboration with the patient, family, and members of the health care team.


Following discharge, the Nurse conducts periodic home visits and/or scheduled phone contacts with the patient based on standard protocol.


Two main focuses of the Nurse home visits and phone contacts are: (a) identifying changes in the patient’s health and (b) managing and/or preventing health problems, including communication with the patient’s physicians.


The Nurse will be available from 8-5 workdays to assist physicians and their staff with needs for these patients in the first 30 days of their discharge.


The Nurse will document their plans, actions, and patient’s response in the patients’ medical record.


Minimum Requirements:


Current licensure as a Registered Nurse in the State of Texas. BSN is preferred. 2 years of hospital experience, preferred Case Management experience.



Contact Information:

Shannon Health

Human Resources


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For questions contact


Mailing Address:                                      Physical Location:

120 E. Harris Ave.                             206 N. Main St.   

San Angelo, TX  76903                     San Angelo, TX  76903