Transitional Nurse Liaison - Hospice

Job Description

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned as necessary.

• Completes an initial, comprehensive and ongoing comprehensive assessment of patient and family to determine hospice needs. Provides a complete physical assessment and history of current and previous illness(es).
• Responsible for obtaining complete / accurate demographic information, medical history including diagnosis for care and primary care physician information.
• Responsible for introducing Residential Hospice to the patient / caregiver, explaining scope of our services, skilled services requested and coordinating start of care visit.
• Other duties include ordering requested DME, infusion services, and coordination of medications upon discharge from acute care setting.
• Patient education at bedside, arranging post discharge physician follow up appointments, sharing important discharge information with the primary care physician.
• Attending discharge planning meeting as requested, working with the facility team to provide a safe and successful discharge home.
• Determining appropriateness of hospice customer.
• Communication with the Clinical team on all complex, chronically ill patients, assisting staff, referral sources in preventing re-hospitalizations.
• Use Liaison Coordination note to communicate information.
• Assist in obtaining regulatory documentation as required.
• Provides professional nursing care by utilizing all elements of nursing process.
• Assesses and evaluates patient's status by :
• Writing and initiating plan of care
• Regularly re-evaluating patient and family / caregiver needs
• Participating in revising the plan of care as necessary
• Initiates the plan of care and makes necessary revisions as patient status and needs change.
• Uses health assessment data to determine nursing diagnosis.
• Develops a care plan that establishes goals, based on nursing diagnosis and incorporates palliative nursing actions. Includes the patient and the family in the planning process.
• Counsels the patient and family in meeting nursing and related needs.
• Provides health care instructions to the patient as appropriate per assessment and plan.
• Completes, maintains and submits accurate and relevant clinical notes regarding patient's condition and care given. Records pain / symptom management changes / outcomes as appropriate.
• Communicates with the physician regarding the patient's needs and reports changes in the patient's condition; obtains / receives physicians' orders as required.
• Communicates with community health related persons to coordinate the care plan.
• Teaches the patient and family / caregiver self-care techniques as appropriate. Provides medication, diet and other instructions as ordered by the physician and recognizes and utilizes opportunities for health counseling with patients and families / caregivers. Works in concert with the interdisciplinary group.
• Provides and maintains a safe environment for the patient.
• Assists the patient and family / caregiver and other team members in providing continuity of care.
• Participates in on-call duties as defined by the on-call policy.
• Supervises ancillary personnel and delegates responsibilities when required.
• Assumes responsibility for personal growth and development and maintains and upgrades professional knowledge and practice skills through attendance and participation in continuing education and in-service classes.
• Actively participates in quality assessment performance improvement teams and activities.
• Prepares and maintains clinical documentation according to Agency policies and acceptable nursing standards.
• Acts as a Customer Service Liaison between Residential Hospice and GIP facilities
• All other duties as assigned by supervisor.

SOC (Start of Care) Responsibilities

RN Case Manager Responsibilities

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.

The low end of the range includes compensation related to salary and first year success bonus. The high end of the range is inclusive of productivity bonuses and additional shift work that is paid at a premium (i.e., after hours, weekends, on-call).

JR# JR250472