Hospice Transitional Nurse Liaison

SUMMARY
Maintain a number of responsibilities for the ongoing daily operation of the Agency. Serve as the primary interface to the Agency's referral sources such as physicians, Hospital SWs and discharge planners, hospital RNs, and all staff in the acute care setting. Obtain complete and accurate information from the patient medical records upon request for our hospice services. Ensure a safe transition from one level of care to another. Gather and share complete information on these complex patients.
ESSENTIAL DUTIES AND RESPONSIBILITIES
include the following. Other duties may be assigned as necessary.
- Complete an initial, comprehensive, and ongoing assessment of patient and family to determine hospice needs, including a complete physical assessment and history of current and previous illness(es)
- Obtain complete/accurate demographic information and medical history, including diagnosis for care and primary care physician information
- Introduce the Agency to the patient/caregiver, explain scope of our services and skilled services requested, and coordinate start-of-care visit
- Order requested DME, supplies, and medications related to hospice care
- Deliver community education as requested for assisted living facilities, skilled nursing facilities, and hospitals
- Provide patient education at bedside regarding hospice, disease progression, and end-of-life care
- Attend discharge planning meeting as requested, working with the facility team to provide a safe and successful discharge home
- Determine hospice eligibility and appropriate level of care
- Communicate with the clinical team on all complex, chronically ill patients, assisting staff and referral sources to prevent re-hospitalizations
- Use Liaison Coordination note to communicate information
- Assist in obtaining regulatory documentation as required
- Provide professional nursing care by utilizing all elements of nursing process
- Regularly re-evaluate patient and family/caregiver needs
- Initiate the plan of care and make necessary revisions as patient status and needs change
- Uses health assessment data to determine nursing diagnosis
- Develop a care plan that establishes goals based on nursing diagnosis and incorporates palliative nursing actions; include the patient and family in the planning process
- Counsel the patient and family in meeting nursing and related needs
- Provide health care instructions to the patient as appropriate per assessment and plan
- Complete, maintain, and submit accurate and relevant clinical notes regarding patient condition and care given
- Record pain/symptom management changes/outcomes as appropriate
- Communicate with the physician regarding the patient's needs and report changes in the patient's condition; obtains/receives physicians' orders as required
- Communicate with community health-related persons to coordinate the care plan
- Teach the patient and family/caregiver self-care techniques as appropriate
- Provide medication, diet, and other instructions as ordered by the physician and recognize and utilize opportunities for health counseling with patients and families/caregivers
- Work in concert with the interdisciplinary group
- Provide and maintains a safe environment for the patient
- Assist the patient and family/caregiver and other team members in providing continuity of care
- Follow up as needed and appropriately with doctor's office and clinical and management staff pertaining to any concerns regarding patient care
- Participate in on-call duties as defined by the on-call policy
- Supervise ancillary personnel and delegate responsibilities when required
- Assume responsibility for personal growth and development and maintain and upgrade professional knowledge and practice skills through attendance and participation in continuing education and in-service classes
- Actively participate in quality assessment performance improvement teams and activities
- Prepare and maintain clinical documentation according to Agency policies and acceptable nursing standards
- Act as a Customer Service Liaison between the company and GIP facilities
- Comply with Company's Core Values and Core Competencies
- Perform other duties as assigned by supervisor
QUALIFICATION REQUIREMENTS
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Associate degree from an accredited School of Nursing
- A minimum of two (2) years of experience working as a Registered Nurse including acute care or oncology experience, hospice experience preferred
- Experience with technologies such as Microsoft Office Suite, EPIC, and HCHB preferred
- Able to meet the physical demands of providing nursing care, ambulating patients, transferring patients, assisting with exercises, etc.
- Able to transfer patients as needed according to proper techniques of body mechanics to promote patient and staff safety
- Able to use good and sound clinical judgment
- Able to document accurately and appropriately
- Hold, in good standing, a license as a Registered Nurse
- CPR certified
- Empathetic, non-judgmental, tactful, responsible, and organized
- Understand the team approach and be a supportive team member
CERTIFICATES, LICENSES, REGISTRATIONS
Must have and maintain in good standing professional license, certificate, or registration, as applicable.
PHYSICAL DEMANDS
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, climb stairs, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.
The employee frequently lifts and/or moves up to 50 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.
WORK ENVIRONMENT
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Employee will be required to drive daily for meetings and/or visits to residential homes. Employee will work in varied residential environments based on assigned case load. While performing the duties of this position, the employee may travel by automobile and be exposed to changing weather conditions.
COMMENTS
This description is intended to describe the essential job functions, the general supplemental functions, and the essential requirements for the performance of this job. It is not an exhaustive list of all duties, responsibilities, and requirements of a person so classified. Other functions may be assigned, and management retains the right to add or change the duties at any time.
NOTICE: Successful completion of a drug screen prior to employment is part of our background process, which includes medical and recreational marijuana.
By supplying your phone number, you agree to receive communication via phone or text.
By submitting your application, you are confirming that you are legally authorized to work in the United States.
JR# JR251468