Hospice Hospital Liaison RN/ 7 on 7 off - Shalom Hospice of Tennessee

Job Title/Position: Hospital Liaison

Reports to: Clinical Director

Job Description Summary: Promotes continuity of care between medical facility, physician and home. Educates and assesses patients referred to hospice/palliative program to ensure hospice criteria is met and informed decisions regarding participation in hospice are made. Facilitates prompt and appropriate delivery of Hospice/Palliative patient care in accordance with Medicare Conditions of Participation.

Essential Functions/ Responsibilities: Establish positive & constructive working relationship with referral sources, with employees and physicians of medical center, skilled nursing facility and home care department and with patients and families. Educate patient, family, staff, physicians and other referral sources regarding Hospice and Palliative coverage and services available after discharge to insure appropriate level of care and utilization of services. Provides agency management with information related to areas of potential growth and methods of improving relationships with medical facilities, referral sources and the community. Accepts and coordinates agency referrals and assesses patients to determine level of care and admission criteria appropriateness, documents pertinent information clearly and accurately according to hospice & palliative guidelines. Prioritize and multitask. Actively participate in Hospice activities including in-services, performance improvement and appropriate committees. Maintains standards of productivity Be at work on time Follow company policies, procedures and directives.

Essential Job Outcomes Assist prospective patient/family in making informed decisions regarding Hospice and or Palliative care via assessment and education. Establish initial plan of care with Patient/family/IDT and establish realistic goals of care. Completes Liaison, Marketing contacts and documents appropriately. Evaluate level of comprehension/response to treatment plan and modify as needed Documentation meets timeliness standards as set by the agency. Meets productivity standards as set by the agency.

Experience Minimum of one-year experience in acute care setting or as a case manager, discharge planner or similar position in an acute care setting.

Patient Care 1. 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).

2. Provides professional nursing care by utilizing all elements of nursing process.

3. Assesses and evaluates patient’s status by: A. Writing and initiating plan of care B. Regularly re-evaluating patient and family/caregiver needs C. Participating in revising the plan of care as necessary

4. Initiates the plan of care and makes necessary revisions as patient status and needs change.

5. Uses health assessment data to determine nursing diagnosis.

6. 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.

7. Initiates appropriate preventive and rehabilitative nursing procedures. Administers medications and treatments as prescribed by the physician in the physician’s plan of care.

8. Counsels the patient and family in meeting nursing and related needs.

9. Provides health care instructions to the patient as appropriate per assessment and plan.

10. Assists the patient with the activities of daily living and facilitates the patient’s efforts toward self-sufficiency and optional comfort care.

11. Acts as Case Manager when assigned by Clinical Supervisor and assumes responsibility to coordinate patient care for assigned caseload.

Communication

1. Completes, maintains and submits accurate and relevant clinical notes regarding patient’s condition and care given. Records pain/symptom management changes/outcomes as appropriate.

2. Communicates with the physician regarding the patient’s needs and reports changes in the patient’s condition; obtains/receives physicians’ orders as required.

3. Communicates with community health related persons to coordinate the care plan.

4. 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.

5. Provides and maintains a safe environment for the patient.

6. Assists the patient and family/caregiver and other team members in providing continuity of care.

7. Works in cooperation with the family/caregiver and hospice interdisciplinary group to meet the emotional needs of the patient and family/caregiver.

8. Attends interdisciplinary group meetings.

Additional Duties 1. Participates in on-call duties as defined by the on-call policy.

2. Ensures that arrangements for equipment and other necessary items and services are available.

3. Supervises ancillary personnel and delegates responsibilities when required.

4. 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.

5. Fulfills the obligation of requested and/or accepted case assignments.

6. Actively participates in quality assessment performance improvement teams and activities.

Position Qualifications:

1. Graduate of an accredited school of nursing

2. Registered Nurse, with a License in good standing to practice in the state of TN.

3. Registered nurses shall have a minimum of (a) one (1) year of experience as a professional nurse within the last three (3) years; OR have a baccalaureate degree in nursing and minimum of two (2) years’ experience, at least one of which is in the area of public health, home care, or hospice nursing is preferred.

4. Management experience not required. Responsible for supervising hospice aides.

5. Once an offer of employment is made, it is contingent upon satisfactory references, as requested, and criminal background checks by regulation.

6. Excellent observation, verbal and written communication skills, problem solving skills, basic math skills; nursing skills per competency checklist.

7. Prolonged or considerable walking or standing. Able to lift, position and/or transfer patients. Able to lift supplies and equipment. Considerable reaching, stooping bending, kneeling and/or crouching. Visual acuity and hearing to perform required nursing skills.

8. Must be a licensed driver with an automobile that is insured in accordance with state/or organization requirements and is in good working order