Rn Comm Palliative Care

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Job Summary:
The Palliative RN Community Based is responsible for coordination of care, care plan development, and skilled nursing assessment of Palliative Care patients that are part of the Community-based Palliative Care program. The care provided focuses on patient-coaching and decision-support, education relating to disease process, and reduction of Emergency Room (ER) visits, inpatient hospitalizations and timely transition to hospice. Primary role to assist Palliative Medicine providers with palliative medicine consult triage and patient follow up visits. The nurse will anticipate and assist with symptom management. He/she will participate in family support, teaching, and continuity of car across sites of care. Contact with patients will primarily be through telehealth with the possibility of occasional home visits in person. He/she will also participate in both formal and informal education for all disciplines.
Core Responsibilities and Essential Functions:
Exemplary Practice and Outcomes
- Performs the Nursing Process (assessment; diagnosis; identification of outcomes; planning; implementation and evaluation) in the performance of clinical care using evidence base practice, uses analytical/critical thinking and ensuring that care is individualized; coordinating care through effective partnerships recognizing that caring is central to achieve optimal patient care outcomes.
- Provides relationship-based patient centered care that is consistent with population specific characteristics (e.g., age, gender, disease, etc.) in a manner that adapts service delivery to reflect an understanding of cultural diversity.
- Always partner with the patient and significant others (as appropriate) using such appropriate method for setting and purpose (e.g., huddles; interdisciplinary rounds; just in time and planned patient teaching; keeping the patient and significant others updated and making the patient's goals the focus of the plan of care.
- Practices using current clinical practice standards.
- Under physician supervision, provides clinical care within the RN scope of practice, documents assessments and reports moderate to distressing symptoms to palliative physicians/APPs.
- Prompt proactive palliative medicine consult based on agreed upon trigger criteria.
- Participates in advance care planning discussions with patients and families and completes documentation (advance directives, DNAR). Teamwork and Collaboration
- Coordinates the delivery and documentation of safe quality patient care that promotes the professional care delivery model. This includes but is not limited to diverse and inclusive interdisciplinary communication methods (interdisciplinary coordination of care, case review, etc.), completion of timely documentation and promotion of a respectful, inclusive clinical environment.
- Participate in developing structures and functions to support the Palliative Care teams' assignments and volumes.
- Coordinate care and communicate between palliative medicine team and referring services as well as patients and families.
- Assists in implementing performance improvement opportunities. Communication
- Communicates plan of care to referring providers and unit clinical teams and ensures palliative medicine physician recommendations are implemented.
- Provides education to patients and their families about Palliative Care, advance care planning, services available.
- Focus on customers, anticipate needs, positively impact patient experience and referring provider satisfaction with service
Required Minimum Education:
Associate's Degree of Science in Nursing Required
Required Minimum License(s) and Certification(s):
Reg Nurse (Single State) 1.00 Required
RN - Multi-state Compact 1.00 Required
Basic Life Support 2.00 Required
BLS - Instructor 2.00 Required
BLS - Provisional 2.00 Required
Additional Licenses and Certifications:
Required Minimum Experience:
Minimum 1 year of Hospice or Palliative Care Required
Required Minimum Skills:
Excellent communication and interpersonal skills.
Demonstrated knowledge about Palliative Care, advanced directives, pain management, symptom control and discharge planning.
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