Nurse Navigator Resume Sample
Work Experience
- Current California RN License and Clinical Nurse Specialist Certification
- Answers patient/family phone calls, fields’ questions appropriately
- Company-paid life insurance
- Voluntary insurance programs
- Leadership Training Program
- Pre-tax Flexible Spending Accounts
- Extensive paid leave for holidays
- Generous Elder Care benefit for family members
- Work directly with appropriate team in maintaining clinical responsibility following company’s nursing and pharmacy policy, as well as Nurse Leadership direction
- Communicates with physicians about patients’ potential for referral
- Serves as the patient family advocate with respect to the patient’s right to privacy by protecting confidential information
- Follows established guidelines for reporting a significant medical error or unanticipated outcome in the patient’s care which results in patient harm
- Assures compliance for studies initiated at St. Mark’s Hospital
- Uses nursing process to assess patient’s condition and to develop a plan of care for the patient and their family to include researching all appropriate or possible clinical trials
- Read and communicate effectively in English. Good computer skills. Team player with excellent communication and interpersonal skills with all levels of internal and external customers (patients, medical staff, support/technical staff, outside agencies, community)
- Serve as patient advocate from diagnosis to end of active treatment
- Assess patients’ medical, social, psychosocial, and other care needs
- Provide appropriate teaching, outreach, and support to patients and families. Ensure the patient is empowered to manage his/her own healthcare needs
- Streamline processes for patients by assisting with appointment scheduling and paperwork preparation
- Coach and assist patients to remove barriers related to insurance coverage, transportation, child care, finances, language, etc. so they can focus on their treatment plan, not these barriers
- Connect patients to hospital and community resources
- Conduct follow-up conversations with all patients and communicate any concerns, changes, or social needs to the appropriate physician or other care provider
- Attend Multi-disciplinary Meetings (MDM) and/or other meetings, as necessary
Education
Professional Skills
- Oversees the continuum of care for patients across the Gentiva/Kindred at Home service lines to ensure each patient receives the right care, in the right place and at the right time
- Skills & Abilities: Excellent interpersonal, communication, critical thinking and analytical skills are required
- Experience: Two (2) years experience as an RN with hematology/oncology experience or three (3) years experience as an RN in another acute care setting
- Effective organizational, leadership and interpersonal skills; verbal and written communication skills in English; competence in Microsoft office software
- Effective listening skills as demonstrated through reflecting, acknowledging, summarizing, empathizing, paraphrasing, and clarifying
- Demonstrates critical thinking skills, scientific judgments, and leadership in planning for the care of the patient
- Highly organized with strong time management and problem-solving skills
How to write Nurse Navigator Resume
Nurse Navigator role is responsible for interpersonal, clinical, nursing, patient, computer, health, leadership, oncology, customer, documentation.
To write great resume for nurse navigator job, your resume must include:
- Your contact information
- Work experience
- Education
- Skill listing
Contact Information For Nurse Navigator Resume
The section contact information is important in your nurse navigator resume. The recruiter has to be able to contact you ASAP if they like to offer you the job. This is why you need to provide your:
- First and last name
- Telephone number
Work Experience in Your Nurse Navigator Resume
The section work experience is an essential part of your nurse navigator resume. It’s the one thing the recruiter really cares about and pays the most attention to.
This section, however, is not just a list of your previous nurse navigator responsibilities. It's meant to present you as a wholesome candidate by showcasing your relevant accomplishments and should be tailored specifically to the particular nurse navigator position you're applying to.
The work experience section should be the detailed summary of your latest 3 or 4 positions.
Representative Nurse Navigator resume experience can include:
- Demonstrates lifelong learning through a knowledge and understanding of best practice and evidence based guidelines for cardiovascular disease management
- Demonstrates effective communication with peers, members of the multidisciplinary healthcare team, and community organizations and resources
- Demonstrates use of evidence applied to clinical practice to achieve improved outcomes
- Demonstrates a genuine, empathetic approach when working to resolve patient/family issues and when offering emotional support
- Three (3) or more years of experience as a clinical nurse in oncology nursing is required
- Demonstrated abilities in the areas of program development, marketing, patient education and event coordination - Required
Education on a Nurse Navigator Resume
Make sure to make education a priority on your nurse navigator resume. If you’ve been working for a few years and have a few solid positions to show, put your education after your nurse navigator experience. For example, if you have a Ph.D in Neuroscience and a Master's in the same sphere, just list your Ph.D. Besides the doctorate, Master’s degrees go next, followed by Bachelor’s and finally, Associate’s degree.
Additional details to include:
- School you graduated from
- Major/ minor
- Year of graduation
- Location of school
These are the four additional pieces of information you should mention when listing your education on your resume.
Professional Skills in Nurse Navigator Resume
When listing skills on your nurse navigator resume, remember always to be honest about your level of ability. Include the Skills section after experience.
Present the most important skills in your resume, there's a list of typical nurse navigator skills:
- Demonstrates strong interpersonal, communication and writing skills; with a high level of initiative and follow-up capacity
- Effective interpersonal communication skills , good organization and multi-tasking essential
- Exceptional communication skills that are demonstrated by effective, empathetic encounters with patients
- Strong and effective interpersonal relationship skills
- Strong program-planning and marketing skills
- Excellent networking, communication and presentation skills
List of Typical Experience For a Nurse Navigator Resume
Experience For RN Nurse Navigator Resume
- Promotes lifelong learning and evidence-based practice, by self and others, to improve the care of patients with a past, current, or potential diagnosis of
- Serves as face and voice of the Center by providing community outreach and education regarding the program, and responding to calls concerning the program
- Collaborative patient care including rounding, equipment needs and discharge planning with communication among all appropriate colleagues
- Works with Cancer Center management in defining and monitoring quality measures and strategic goals for the program
- Participate in training and education for hospital nurses on latest developments in the neuro spine and orthopedic nursing profession
- 2 Collaborates with Corporation Communication Department regarding marketing strategies for the Chronic Disease Education Programs
- Functions as a liaison between patients, families, health care team and community resources. Advocates identifying and eliminating barriers to care
- Serves as a liaison for referring physicians seeking information, or access to the system
- Takes the initiative to actively build great teams through communication, coaching, shift activities, and resolving challenges
Experience For Chronic Care Nurse Navigator Resume
- Stay current on the latest oncology nursing developments and participate in organizational conferences
- Participates in the development, monitoring, and improvement of neurosurgical clinical
- Stay current on the latest neuro spine and orthopedic nursing developments and participate in conferences
- Plays a vital role in coordinating the multiple and complex technologies that are now commonly a part of diagnosis and treatment of chronic diseases
- Provides health education to individuals and groups. Develops and maintains a learning library for patients that include language specific materials
- Works with the interdisciplinary team throughout the continuum of oncology care to facilitate diagnostic testing and treatment
- Coordinate and participate in the delivery of patient care ensuring compliance with physician and APP orders and established policies and procedures
Experience For Nurse Navigator Oncology Resume
- Responsible for the planning and implementation of the patient evaluation process
- Coordinate and lead monthly Structural Heart education conferences for medical and nursing staff as requested and needed
- Participates in action planning for staff development
- Communicates with peers on a daily basis regarding service delivery and issues that need to be resolved
- Management of assigned projects on a daily basis including initiation, follow-through and completion of the project
- Serves as an active member of the team, working to ensure the clinical and budgetary efficiency of the department
- Works with the Outreach and Referral Manager to develop and implement survey tools for referring physicians and cardiac families
Experience For Oncology RN Nurse Navigator Resume
- Provides feedback including market intelligence information as appropriate to the Service Line Director and Outreach and Referral Manager
- Document throughout patient care continuum in iNavigate database
- Oversees all aspects of the Total Joint program. Facilitate program development and oversees the navigation and day to day management of patients within the Total Joint Program
- Coordinate necessary meetings with all participating parties within the Total Joint Program, including physicians, surgical/OR services, nursing, case management, physician office staff and post- acute providers
- Facilitate development and monitor compliance with standardized systems of care within the Total Joint Team including pre-op, post-op and discharge orders
- Serve as the clinical resource for joint replacement care best practice by educating staff, monitoring patient care, and advocating for necessary elements of care which require continued education, benchmarking, and networking with other centers
Experience For Structural Heart Nurse Navigator Resume
- Responsible for developing and enhancing pre surgical education class (Joint 201). Responsible for distributing patient teaching materials to physician offices and overseeing the development and on-going editing of all program forms and materials
- Responsible for Continuous Quality Improvement (CQI) activities including: Tracking surgical outcomes discharge phone calls, patient satisfaction, patient volumes, length of stay, and readmission data
- Assist in assuring standards are met and maintained for Joint Commission Orthopedic recertification
- Maintains the Neurosurgical Outcome Database
- Assists with the development and revision of neuroscience related policies, procedures and patient education materials
- Provides professional neurosurgery patient and family education
- Patient Referral. Uses clinical protocols to refer patients to appropriate specialist for diagnosis or treatment and assists patients and their families in obtaining referrals to needed specialists. Provides support and counseling, as appropriate to the clinical situation
- Clinical Protocol Development. Works with Director and Nurse Practitioner to develop and maintain clinical protocols specific to the pre- and post-operative care of bariatric surgery patients. Updates pathways as needed to maintain highest quality of care
Experience For Rn-nurse Navigator Resume
- Clinic Improvement. Proactively develops and enhances processes with the goal of improving the clinical experience for referred patients and the referring physician. Actively pursues research in quality improvement to maximize program outcomes
- Liaison. Communicates with referring physician’s offices as appropriate to the patient and physician’s needs. Serves as the liaison between the Director, the program, and ASMBS
- Patient Education. Works with marketing and outreach departments to educate referring physicians and facilities on available services. Works with Director, Nurse Practitioner, and dieticians to develop patient seminars. Teaches patient seminars in conjunction with Director, Nurse Practitioner, and dieticians
- Nurse Education. Works with Director and Nurse Practitioner to develop and deliver education for nursing staff in the clinic and the hospital setting
- Accreditation. Actively pursues accreditation. Reviews and organizes program, clinical staff, and clinical facilities to maintain accreditation once obtained
- Data Collection. Works with Clinical Reviewer to ensure timely submission of outcomes data
Experience For Remote Telehealth Nurse Navigator Resume
- Provide a personalized touch to cancer care by visiting patients at appointments, assessing patients’ needs, and relaying relevant information to providers
- Location/Facility – Baylor Scott & White Medical Center – Irving
- Organized and able to multi-task while working in a tough, stressful condition with a positive attitude
- Understand and apply current clinical guidelines in implementing a treatment plan
- Location/Facility – Baylor Scott & White All Saints Medical Center - Ft. Worth
- Demonstrates the ability to apply the nursing process effectively in the care of culturally diverse patients and families. Demonstrates an ability to apply all policies, standards, guidelines, and evidenced-based practice in the provision of patient and family care
- Consistently and thoroughly assesses patient needs to collect data and identify learning needs according to established standards and policies
- Utilizes the systematic and complete analysis of assessment data to develop individualized problem lists and care plans for assigned patients
- To ensure effective implementation of the patients plan of care in accordance with applicable standards, policies, procedures, and guidelines with the interdisciplinary health care team
Experience For LVN Nurse Navigator Resume
- Demonstrates the ability to assess the patient and family learning needs, readiness to learn, learning style, and presence of barriers to learning. Demonstrates the ability to develop and implement teaching plans for patient populations in unit specialty in accordance with applicable standards
- Possess good analytical and deduction skills
- Previous Nurse Navigator experience
- Plans of care addresses the physical, psychosocial, spiritual, and learning needs of the patients/family
- Provides care to patients and families in a culturally, developmentally, and ethically appropriate manner
- Be sympathetic and provide emotional support to the patient
- Knowledge of pathophysiology of specific disease processes and understands oncology treatment modalities and rationale including surgery, chemotherapy, symptom management, survivorship, surveillance and radiation therapy
- Manage physical, mental, psychological and/or spiritual well-being while working with the patient to develop a treatment plan and contribute to its implementation and evaluation
- Coordinates the development of a site specific cancer programs as a core member of the site specific steering committee consistent with the mission and core values of the hospital
Experience For Nurse Navigator Orthopedics Resume
- Provide continuity of care throughout the entire cancer care experience from pre-diagnosis through survivorship, palliative/hospice care and end of life
- Respond appropriately to instances of unsafe practice to safeguard the patient’s health
- Assess the health needs of the patient using a bio-psycho-social-spiritual framework including self-determined health goals and develop a plan of care for the patient based on his or her own personal needs
- Participates in national and local professional oncology nursing organizations, reviews oncology literature and assess trends in patient care needs and development of services and resources to meet these needs
- Performs nursing techniques proficiently by maintaining accurate documentation, using appropriate channels of referral and working effectively with other health care team members
- Assessment of patient’s ability to navigate through the healthcare system and identify potential barriers. Guide patient through the healthcare system including
Experience For Cardiovascular Services Nurse Navigator Resume
- Advocate and facilitate access to the appropriate services to individuals with disabilities and advocate for equal access for all patients regardless of financial status
- Demonstrates ability to be self motivated with strong and positive interpersonal skills
- Contact patients prior to surgery or treatment for patient education; ensure patients know what to expect before, during, and after procedures
- Assesses, plans, implements and evaluates patient care according to the nursing process and Oncology Nursing Society Standards of Practice
- Identifies funding sources and actively pursues funding from within CPMC as well as community and government sources (grants, etc.)
- Assists with the tracking and monitoring of center accreditation standards, Commission on Cancer guidelines
- Advocate for the patient’s right to autonomy and an informed decision making process
- Identify and implement methodologies for continuous quality improvement within the oncology service line and support disease specific performance improvement initiatives
List of Typical Skills For a Nurse Navigator Resume
Skills For RN Nurse Navigator Resume
- Strong interpersonal communication and customer relation skills required, with excellent written and verbal communication skills
- Act/communicate professionally – excellent verbal, written and interpersonal communication skills and conflict management skills
- Experience: Two (2) years experience as an RN in specialty area or three (3) years experience as an RN in another acute care setting
- Able to work independently, prioritize effectively, and implement critical thinking
- Effective problem solving, organizational and time management skills with the ability to consistently work in a fast-paced environment
- Dosage calculation skills as proven by successful completion of the medication test
- Demonstrated skills and expertise in the areas of cancer disease, treatment and psychosocial impact
Skills For Chronic Care Nurse Navigator Resume
- Good use of written and oral communication skills targeted to audience, i.e. provider versus patient
- Demonstrates leadership and problem-solving skills
- Demonstrated skills and expertise in the areas of breast disease, treatment and psychosocial impact
- Demonstrated management and collaboration skills
- Demonstrate effectiveness in teaching, organizing, planning and developing programs
- Preferably with care management experience in acute setting, experience in community nursing, critical care or emergency department
- Experience:Three (3) years experience as an RN in an acute care setting
- Clinical experience in inpatient setting and home care experience as an RN
Skills For Nurse Navigator Oncology Resume
- Effectively communicating with office and referral sources
- Comfortably and effectively interact with diverse populations
- Great communication skills and with multi-disciplinary team
- Demonstrates experience interacting with community organizations
- Three (3) years of direct nursing experience and demonstrated clinical competence required
- Utilize advanced clinical thinking and analytical skills that contribute to patient adherence of treatment protocols and symptom management required
- Nursing experience in oncology
Skills For Oncology RN Nurse Navigator Resume
- Five (5) years of experience working in a clinical setting
- Disseminates knowledge of the ONN role to other healthcare team members through peer education, mentoring and preceptor experiences
- Licenses/Certifications: Registered Nurse, current license and in good standing in the state of Texas. Basic Life Support certificate
- Three years of direct nursing experience
- The ability to be self-motivated and use effective problem-solving techniques required
- Experience as a RN in an inpatient or outpatient setting
- Experience in successfully coordinating MQSA and ACR accreditation surveys
Skills For Structural Heart Nurse Navigator Resume
- Acute Care Nursing Experience
- Valid nursing license in the state of the position or compact state license required
- Experience: 2-3 years acute care hospital setting
- Related work experience required in caring for surgical patients
- Works with the AVPO HO, AVPO HH, ADO HH and DCO to determine priorities and needs across the local market area.
- 2 Demonstrates an attitude which encourages positive and open communication
- 4 Evaluates effectiveness of interventions
- Prioritize and manage caseload with multiple interruptions
- Provides accurate and consistent information and formulates and recommends a plan and validates the plan with the patient for completeness and accuracy
Skills For Rn-nurse Navigator Resume
- Chemotherapy and Biotherapy administration experience
- Healthcare experience required
- Experience with direct member communication (written and oral)
- Medical research and women's experience
- Experienced in the administration of blood products and the recognition and management of blood transfusion and blood reactions
- Demonstrate competence in clinical specialty (Sickle Cell)
- Demonstrated ability to analyze, summarize and concisely report medical utilization, and medical chart audit results
Skills For Remote Telehealth Nurse Navigator Resume
- Direct care experience in the treatment of Oncology patients
- Experience as a Nurse Navigator or RN Case Manager
- Completion of Accredited RN Program and Clinical Experience
- Five (5) years experience as Registered Nurse
- Two (2) years experience as Registered Nurse in Oncology related field
- Good understanding of women’s breast disease issues, diagnosis and treatment
- ) nursing experience in the specialty required
- Demonstrated mastery-level understanding of oncology patient care and services
Skills For LVN Nurse Navigator Resume
- Flexible, with a strong ability to adapt to change
- Five years current RN experience in an acute care and/or Palliative Care setting
- Coordinates and navigates the patient experience throughout the healthcare continuum
- Performs coordination of care during the full continuum of health care experience
- Electronic Health Record (EHR) Management.Demonstrate proficient use of an EHR – including accurate patient and provider documentation and communication
- Related work experience required in clinical medical-surgical
- Valid State Of Ohio Nursing required
- Develops and implements protocols for care of structural heart patients which are evidence based
Skills For Nurse Navigator Orthopedics Resume
- Planning, scheduling and implementing daily clinical activities
- Tracking and monitoring clinic volumes and trail enrollments
- Working with a multidisciplinary team
- Connecting patients to right resources
- Working with referral resources to ensure seamless care between sites
- Sharing clinical trial information with referral sources
- Nursing. Works as a Staff Registered Nurse when needed
- Providing initial detailed patient/family needs assessment and periodic updates throughout the course of care
Skills For Cardiovascular Services Nurse Navigator Resume
- Attends Patient/ family Care Conferences when requested to assist in discussing or explaining care setting options
- Maintains current lists of all pending Hospice Live Discharges, Patients not taken under care or seeking aggressive treatment, and Home Health Hospital holds
- Works closely with both Home Health Branch Directors and Hospice Executive Directors to assure each patient is receiving care in the right setting
- 7 Collaborates with other health care providers to implement plan of care, including discharge planning
- Familiarity working in an electronic medical records system, preferably working with population health management programs, such as disease registries
List of Typical Responsibilities For a Nurse Navigator Resume
Responsibilities For RN Nurse Navigator Resume
- Strong communication skills required to effectively communicate procedures and results with patients and families
- Basic computer skills and familiarity with general office equipment
- Basic computer skills required, MS Word and Excel
- Or more in an acute care setting of clinical nursing experience
- At least five years of experience treating and managing cancer patient population
- Oncology nursing experience
- Approximately three to four years of progressively more responsible clinical nursing experience in specialty area is required
- Computer literate and database managing experience
Responsibilities For Chronic Care Nurse Navigator Resume
- Demonstrated knowledge of disease processes
- Experience with women’s breast care issues and breast care education
- Previous experience with patient satisfaction initiatives
- Establish appropriate mechanisms to ensure service continuity during both planned and unplanned absences and undertake succession planning
- 2 Include age specific information when gathering data or performing assessments
Responsibilities For Nurse Navigator Oncology Resume
- Test and pilot new VBC initiatives and work with leadership on refining processes, helping Division achieve contractual metrics
- Serve as patient advocate from first suspicious finding to treatment plan and subsequent screenings
- Initiate contact with patient and introduce navigation program and role at time of suspicious finding (or at entry into the HCA care system, if later) and to navigate the healthcare system
- Three to five years orthopedic nursing experience
- Attend Interdisciplinary Rounds, Neuro Spine and Orthopedic Steering Committees, and other meetings as necessary
- 6 Involves families and/or significant other(s) in decision making related to plan of care
- Hospital based computing systems (i.e. Meditech),
Responsibilities For Oncology RN Nurse Navigator Resume
- Oncology Nursing Society Certification required within 1 year of date of hire
- Currently licensed as an RN in the state(s) in which they are practicing (Illinois and Michigan). BSN or BSN within 6 years of hire (signed agreement required)
- Member of Oncology Nursing Society
- Rapid appointment scheduling or hospital-to-hospital transfers for critically ill patients
- Close contact with refering physicians
Responsibilities For Structural Heart Nurse Navigator Resume
- Performs needs-based assessment of patient and available family members for the ability and understanding for early language development
- Clinical nursing practice in oncology
- Understands, develops, and facilitates goals,treatment plans and provider options according to specific standards/guidelines of the patient population
- Assesses patient needs and coordinates education, discharge planning, development of a post-acute care plan, and coordination of post-acute services
- 5 Re-evaluates plan of care at each consultation, making revisions as necessary
- Respond to patient challenges until resolution is achieved
- Assess patients’ medical, social and psychosocial and other care needs
- On an individual basis use appropriate tools to identify need and potential resolution, e.g. quality of life assessments, clinical research study selection criteria
Responsibilities For Rn-nurse Navigator Resume
- Provide appropriate teaching, outreach, and education to patients and families. Ensure the patient is empowered to manage his or her own health
- Identify health disparities and remove barriers to care, e.g. referral pathway barriers
- Provide education on subjects that fall beyond the scope of individual modalities, e.g. access to supportive care, financial support, return to work
- Provide education through formalized routine groups or classes to meet identified unmet needs in the community
- Initiate referrals to hospital and community resources to connect patients with resources and support systems
Responsibilities For Remote Telehealth Nurse Navigator Resume
- Conduct follow-up conversations as needed with all patients and communicate concerns, changes, or social needs in patient health to appropriate MD or other appropriate care providers
- Ensure that appropriate patient data is available and patients are appropriately assessed and documented at patient care planning conferences including identification of appropriate clinical research study options
- Contribute, as appropriate, to patient care planning conference based on assessed patient need
- Track and document interventions and outcomes
- If appropriate, support definition of datasets and ensure appropriate data is collected to track system interventions and outcomes
- Work with data experts such as cancer registrars to support collection of data, e.g. national quality measures
- Conduct outreach to referrers, providers and other medical professionals as well as to the corporate ‘customer’ community [Optional by market]
Responsibilities For LVN Nurse Navigator Resume
- Establish and maintain positive working relationships with key internal and external customers (including physicians, nurses, radiology staff, social services staff, radiation oncology staff, business office staff, etc.)
- Provide referrers with timely data on patient progress
- Facilitate resolution of customers’ questions
- Address patient’s, caregivers’ concerns about the disease and its treatment and provides support throughout the course of treatment
- Support the prompt identification of the DRG’s for the staff at assigned location in the Bundling program; track assigned patient population over a 90 episode that begins with admission to the SNF participating in Bundling; track the patients and monitor by the assigned DRG
- Support assigned Centers as they develop Care Paths and their Quality initiatives designed for certain DRG’s
- Identify all three sets of quality measures (Hospital Quality Measures, MD Measures, and Episode Initiating SNF’s) are captured on each episode record for all patients included in the Bundled Payment Program who’s DRG’s match those included in the program
Responsibilities For Nurse Navigator Orthopedics Resume
- Basic Computer Skills regarding the use of email, and WORD; processing fax’s and messages, email etiquette
- Facilitate new cancer patients getting an appointment in a timely manner by assessing urgency of request and discussing with provider as needed to ensure patients are seen promptly
- Assess barriers to care and engage patients and families in creating potential solutions to financial, practical and social challenges
- Identify appropriate and credible resources responsive to patient needs taking into consideration health literacy, culture, language and amount of information desired
- Educate patients and caregivers on the multi-disciplinary nature of cancer treatment, the roles of team members and what to expect from the health care system
Responsibilities For Cardiovascular Services Nurse Navigator Resume
- Empower patients to communicate their preferences and priorities for treatment to their health care team; facilitate shared decision making in the patient’s health care
- Follow up with patients to support adherence to agreed-upon treatment plan through continued collaboration with the clinical team
- Current license as RN in Florida
- Works closely with physicians in all specialty areas to coordinate patient’s care plan communication; works with multidisciplinary team to maintain and implement up-to-date coordinated patient centered care plan; communicates with all members of the healthcare team as patient advocate
- Work alongside the THR Patient Access Intake Center for smooth pre-registration, verification, and coding
- Work with the physician offices to ensure proper and timely notification is provided as well as education about the procedure/episode process. Validate all pre-operative work-up is done at a network provider
- Develop a follow-up plan to keep track of post-surgical patients (ensuring proper post-surgical care, while at the same time reducing the risk of readmission)