Transitional and Complex Care Nursing: unique skills for exceptional situations

Northwell Health Solutions is enhancing patient care while improving the overall health and wellness of the communities we serve.

We focus our resources to empower patients, families and providers so that together they can ultimately achieve improved patient outcomes. In this work we safely transition patients from hospital to home and empower patients with chronic and complicated medical conditions to make the best health care decisions for themselves. Our services don’t end at the hospital doors, but rather, they extend into the homes of our patients and the communities we serve. Caring runs through everything we do.

Helping patients return home.

Transitional Care involves decisions and actions that enable patients to make the transition from an inpatient setting to the comforts of home. This includes medication reconciliation, discharge instruction review, scheduling appointments with PCPs and specialists and resource coordination. In many ways, this is very different from traditional nursing roles. It involves a great deal of one-to-one patient engagement, in person and on the phone. The nurses who take on this role must be comfortable working within each patient’s specific home environment – from houses and apartments to group homes and assisted living communities.

“In addition to their clinical skills, the best nurses for transitional care will possess a lot of qualities you just can’t teach, such as tremendous warmth, hospitality and the ability to encourage patients to buy into the program.”

–Dr. Zenobia Brown, Medical Director, Northwell Health Solutions

Helping patients stay healthy, after care.

Complex Care involves the care of high-risk patients in our practices and communities. It means working with patients to promote healthy living, so that hospitalization doesn’t become necessary. Each personal nurse care manager provides a full health risk assessment (HRA), individualized care plan and ongoing support.

Our employees serve the needs of our patients in the community, working to improve patient care and reduce the need for medical services by helping patients and caregivers more effectively manage health conditions. Our nurses work within a variety of practice settings and geographic areas to provide face-to-face as well as phone contact with our patients. This role requires a high degree of flexibility and adaptability, and feeling comfortable on the go in a changing environment.

“To work in Complex Care, you must be self directed, outgoing, proactive and possess strong time management skills in order to cover a multitude of practices. We’re looking to you to build great relationships with providers, patients, staff and family.”

–Mary DiCostanzo, ‎AVP, Complex Care Management, Northwell Health Solutions

Are you Made for this?

Northwell Health Solutions is helping define a new model of caring, one that is uniquely focused on helping people recover and maintain their health and wellness, outside the traditional hospital setting. With our strong, consistent growth, we have amazing opportunities for ongoing development, in a unique career path. But it’s not a career path made for just anyone. We’re looking for nurses who work hard and aren’t afraid to push boundaries to go the extra mile. If you think you’re made for caring for our patients and communities, you might be Made for this.

Health Solutions – Search career opportunities with Northwell Health!