Hospice Alliance
Job Title: Hospital Liaison -Hospice and Palliative Care (HLHPC RN)
Reports to: Clinical Team Manager
Hours: Core work hours for this position are between the hours of 9am to 5:30pm. This position also participates in the weekend and holiday rotations
GENERAL DESCRIPTION
Summary
The HLHPC RN plans and delivers care to patients utilizing the nursing process of assessment, planning, interventions, implementation, and evaluation; assesses patients for hospice eligibility and the appropriate level of care; and effectively interacts with patients, families, and other interdisciplinary team members while maintaining standards of professional nursing and clinical competency.
The HLHPC RN will be located within the hospital and available for consultations and admissions as referrals are made. Will make daily/PRN visits to admitted hospice patients, to assist and educate nursing and physician staff with recognizing potential referrals further upstream, including seeing patients in the Emergency Department, and assisting hospital staff with goals of care and engaging in clinical conversations/discussions. In addition, the HLHPC RN is responsible for generating referrals for hospice and palliative care by building relationships with hospital staff and physicians through communication, education and collaboration. The HLHPC RN will meet with patients and their families to ensure a smooth transition of care throughout the admission to transfer or discharge process. The HLHPC RN will be responsible for explaining care options to patients and their families, reviewing the patient’s medical records and verifying eligibility for care. Visits/Assignments made are directed and guided by the RN responsible for leading the shift. HLHPC RN will perform consultation and admission visits to assess patient’s needs, complete the admission assessment, contractual agreements, and all necessary documentation. In addition, this role will make routine and emergency visits to Hospice and Palliative Care patients in facilities, homes and Hospice House.
Physical Demands
Must have visual and hearing acuity.
Must be able to communicate verbally.
May be exposed to pets, smoke, minor hazards, blood borne pathogens and communicable diseases.
Physically active walking, standing, bending, lifting, and climbing stairs.
Must be able to perform fully assisted transfers, with or without transfer devices.
Work Environment
Provides direct patient care in the hospital setting majority of the time or in patient homes, skilled nursing facilities, and other residential type settings.
Travel is required and reliable transportation, proof of automobile insurance upon hire and at each renewal and maintaining a safe driving record is required.
Exposure to inclement weather.
ESSENTIAL DUTIES AND RESPONSIBILITIES
- Serves as the primary referral contact between assigned hospital partners and our hospital partner.
- Works with intake coordinator/billing to verify insurance coverage.
- Provide education to medical and nursing staff on hospice and palliative care options and goals of care.
- Establishes and fosters professional relationships with physicians, case managers, discharge planners, and social workers employed by the hospital.
- Performs clinical assessment of potential referrals to determine appropriateness against eligibility criteria.
- Ensures a smooth transition of care from hospital to home by assessing and communicating all patient needs prior to discharge
- Make regular planned visits to hospital patients and will be available by phone during business hours.
- Participate in hospital rounds as directed by hospital leadership.
- Communicate regularly with hospice leadership on conflicts, obstacles, performance improvements suggestions, educational and other identified needs
- Will make visits, complete admissions for other hospice patients as schedule allows
- Works directly with Intake Coordinator or Clinical Teams Manager re: schedule
- Actively case manages patients admitted under the GIP level of care.
- Responsible for completion of all elements of the admission process and patient care until the RN Case Manager has been assigned.
- Responsible for assessing the patient’s medical status, planning, teaching, and implementing immediate medical interventions on the day of admission.
- Initiates the Plan of Care.
- Provides patient and family education.
- Completes Medication Reconciliation, coordinates medications and DME needs.
- Collaborates with attending physician, Hospice Medical Director, Palliative Care NP, Director of Operations, Social Worker and other involved personnel regarding the patient’s admission and follow up needs.
- Performs timely administrative functions and documents all patient information in a timely and accurate manner.
- Communicate information, issues, and concerns in patient care meetings to assure smooth transition and continuity of care with other assigned staff, including a detailed report to the assigned Case Manager and assigned Social Worker.
- Provides consultation and emotional/physical support to patients/families regarding Hospice services and the disease processes.
- Assesses home care needs, being aware of the physical, emotional, and spiritual aspects and gathers data on social, economic, and cultural factors which may influence health, well-being and quality of life.
- Participates in the agency’s on-call rotation as prescribed by the needs of the agency to provide nursing service to clients when required outside of office hours.
- Comply with Hospice Alliance policies, standards of practice and operational guidelines.
- Participate in hospice and community health programs as requested to promote the growth and understanding of the hospice concept. This includes but is not limited to participation in the Hospice Alliance observation program that provides other health care professionals with the opportunity to observe and learn about hospice care, college partnerships, and other Hospice Alliance sponsored education events.
- Establish a CNA plan of care as well as indirectly and directly supervising the plan of care per regulations.
- Participation in Hospice Alliance town hall meetings, clinical team meetings, trainings, memorials, and other events.
- Conduct skilled nurse visits during periods of down-time in the admissions department.
- Maintain the dignity of the dying patient and support the patients and family’s unique spiritual and cultural beliefs.
- Support, instruct/train and educate the patient, family and caregivers.
- Performs other duties as assigned consistent with skills and training and the mission and goals of Hospice Alliance.
EDUCATION AND/OR EXPERIENCE OF CERTIFIED NURSING ASSISTANT
- Graduate of an accredited school of nursing. BSN preferred.
- Valid license as a Registered Nurse in the State of Wisconsin.
- Certification as a Certified Hospice and Palliative Care Nurse (CHPN) desired.
- Current Basic Life Support Certification.
- Valid Driver’s License and car insurance