RN- Hospice Transitions - Admin RN
RN- Hospice Transitions - Admin RN
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1 Vacancy
Job Description
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Overview
The Hospice Transitions RN as a member of the Advanced Care Management department identifies assesses and prepares hospitalized patients and their loved ones for the transition to end-of- care. Coordinates the discharge plan problem solves and documents actions and plans while collaborating consulting and advocating on the patients behalf. Holding continuity of care as a priority communicates and coordinates with the larger healthcare team including the hospitalist nurse patient care facilitator social worker and palliative care. Receives and follows up on hospice referrals by meeting with the patient/family introducing hospice services evaluating the patients status eliciting choice for post-acute providers facilitating orders and anticipating needs for equipment medication and transportation
Qualifications
Education:
- Graduate of an accredited College of Nursing with a Bachelors degree required.
Licensure/Certification/Registry:
- IL Licensed Registered Nurse required.
- CPR Certification required.
Experience:
- Minimum three (3) years in nursing experience required.
- One (1) year experience in hospice or palliative care required.
- Experience in acute-care hospital setting; knowledge of discharge planning/case management preferred..
Other Knowledge/Skills/Abilities:
- Must have clinical knowledge and critical thinking ability to create a viable and effective patient transition plan an identify barriers in service effectively conduct verbal and written patient assessments carry out the referral processes and coordinate with other individuals involved in the plan of care.
- Understanding of home hospice services and regulations.
- Knowledgeable about disease states and prognosis and how illness progresses clinically and functionally.
- Self-starter with a high degree of initiative
- Ability to work as part of a team as well as form harmonious working relationships with post-acute providers
- Excellent collaborative and problem solving skills
- Excellent organizational skills
- Excellent interpersonal and communication skills
- Strong commitment to teamwork and patient experience
Responsibilities
- Identifies assesses and prepares patients (and their families) for transition to home hospice care
- Reviews hospital plan of care and current discharge planning efforts
- Gathers additional information from the patient/family interviews medical record physicians and other healthcare providers
- Understands current and future disease states and can accurately match patients needs to appropriate level of service
- Formulates a transition plan after reviewing available/appropriate care options and obtaining input from the patient/family and the physician healthcare team and post-acute care providers
- Identifies patients person-centered goals-of-care and provides education to the patient and family about home hospices line of services that would help meet those goals
- If needed for hospice patients receiving General Inpatient Level of Care assist with admissions and daily visits when directed coordinate with the hospice Interdisciplinary team
- Maintain accurate daily documentation including patient assessments plans interventions patient/family involvement coordination with physicians colleagues and post-acute care providers
- Coordinates care problem solves and documents actions and plans
- Utilizes professional judgment to determine the need for a family meeting escalation to leader and other problem solving measures
- Monitors transition plan and intervenes in an appropriate and timely manner with difficulties arise
- Identifies communicates and creatively develops efficient delivery of care as the patient moves to home hospice services
- Enters referral information and documents interactions in the appropriate electronic medical record
- Collaborates consults and advocates
- Develops and maintains positive productive relationships with colleagues
- Provides educational opportunities in hospital collaborating with peers and palliative care team as appropriate
- Actively participates in rounds with other team members to effectively coordinate and facilitate transition plan
- Adheres to departmental and organizational protocols policies and procedures and supports operational and strategic plans and objectives
- Demonstrates competencies related to service line knowledge edibility criteria regulations and processes
- Adapts to changes in the work environment or work process in a timely positive and effective manner
- Demonstrates a commitment to teamwork by willingly accepting responsibilities and performing assignments that support the team
- Completes all annual competency validation requirements
- Actively participates in department meetings and operations
- Identifies new systems or processes protocol and/or methods to improve practices
- Maintains confidentiality of patient information
- Demonstrates knowledge of appropriate utilization of internal and externa resources to meet patients needs
- Ensures quality standards are met. Follows all applicable licensure regulations and commonly accepted professional standards of practice
- Utilizes time well to ensure follow-up is completed and needs of patient/family or healthcare providers are anticipated and proper plans are executed.
- Performs other related work as required or requested.
The intent of this job description is to provide a representative summary of the major duties and responsibilities performed by incumbents of this job. Incumbents may be requested to perform tasks other than those specifically presented in this description.
Employment Type
Full-Time
