Admissions and Transitional Care Nurse

Hope Hospice • New Braunfels, TX

3d • Hybrid

About The Position

This position is responsible for receiving referrals, performing initial assessments, coordinating the establishment of the plan of care, and collaborating with the interdisciplinary team. The nurse works Saturday, Sunday, and Monday. On Monday, the nurse assumes responsibility for General Inpatient care patients admitted over the weekend, including assessment, symptom-management coordination, physician collaboration, and discharge planning. After all GIP patients have been seen and their immediate needs addressed, the nurse completes any remaining admissions as assigned. The role involves travel to patient homes, hospitals, nursing facilities, and other care settings.

Requirements

• Graduate of an approved school of nursing.
• Current license to practice professional nursing in the State of Texas.
• Reliable means of transportation.
• Valid Texas driver's license.
• Automobile insurance.
• One or more years of clinical nursing experience.
• Understanding of family dynamics, conflict resolution, and principles of adult learning.
• Professional appearance, behavior, attitude, and integrity.
• Ability to work independently and interact effectively with patients, families, facility staff, physicians, and coworkers.
• Demonstrated flexibility, self-motivation, dependability, and commitment to teamwork.
• Effective verbal and written communication skills.
• Working knowledge of computers and electronic medical records.
• Critical-thinking and problem-solving skills, including the ability to make decisions, set priorities, and maintain timely, accurate, and orderly records.

Nice To Haves

• Bachelor of Science in Nursing degree.
• Strong assessment skills and experience with an interdisciplinary approach.
• One year of experience as a case manager for Hope Hospice.
• Pain and symptom management skills.
• Crisis intervention expertise.
• Patient and family teaching and counseling skills.

Responsibilities

• Receives referrals, performs initial assessments, and coordinates the establishment of the plan of care.
• Collaborates with the interdisciplinary team.
• Works Saturday, Sunday, and Monday, providing admission coverage based on referrals, patient needs, and operational priorities.
• Assumes responsibility for General Inpatient care patients admitted over the weekend, including assessment, symptom-management coordination, physician collaboration, and discharge planning.
• Completes any remaining admissions after addressing GIP patients and care coordination.
• Maintains flexibility in daily scheduling to respond to patient acuity, referral volume, travel requirements, and changing organizational needs.
• Visits patients to assess compliance with hospice admission criteria and performs comprehensive initial nursing assessments.
• Communicates findings to the Medical Director and attending physician to complete the start of care and begins coordination of services.
• Educates patients and families about hospice services, assesses needs and preferences, and initiates referrals for needed services.
• Ensures the initial plan of care is based on a comprehensive assessment of physical, psychosocial, safety, age-related, spiritual, financial, environmental, and cultural needs, resources, and preferences.
• Ensures the initial assessment includes pain and symptom assessment, history of interventions and responses, and evaluation of patient and caregiver knowledge and learning needs.
• Reviews the plan of care with the assigned nurse, chaplain, social worker, hospice aide, and other appropriate team members.
• Completes all electronic communication and documentation accurately, completely, and within required timeframes.
• Effectively and professionally collaborates, coordinates, and manages relationships with referral sources, facility/hospital staff.
• Reviews the weekend handoff and identifies every GIP patient admitted on Saturday or Sunday before beginning Monday field visits.
• Completes an in-person nursing visit for each weekend GIP admission and evaluates continued eligibility for GIP level of care, current symptom burden, response to interventions, medication effectiveness, and changes in condition.
• Provides active clinical management of assigned GIP patients until responsibility is formally transitioned.
• Collaborates with the hospice physician and attending physician regarding symptom management, continued GIP eligibility, medication or treatment changes, and readiness to transition to a lower level of care.
• Collaborates with the social worker, hospital or facility care-management staff, patient, and family to begin or advance discharge planning.
• Identifies the anticipated discharge setting, caregiver availability, equipment, medication, transportation, education, and other services needed for a safe transition.
• Keeps the patient and family informed of the plan of care, the purpose and daily review requirements of GIP care, and expected next steps in discharge planning.
• Communicates the patient's status, barriers, orders, and discharge plan to the interdisciplinary team and appropriate clinical leadership.
• Documents the visit, assessment, physician communication, interventions, patient response, continued GIP eligibility, and discharge-planning activity accurately and timely in the electronic medical record.
• Coordinates development of the initial plan of care with interdisciplinary team members.
• Presents new patient admissions at the interdisciplinary team meeting as assigned.
• Provides clear handoff communication to the assigned case manager and other team members to support continuity of care.
• Creates opportunities for new referrals while working in the community.
• Presents Hope Hospice programs and services to others in the community as a member of the agency-wide marketing team.
• Supports the philosophy and objectives of Hope Hospice.
• Maintains professional competency and licensure.
• Stays current with accreditation standards and governmental regulations affecting hospice care.
• Works effectively both independently and within the interdisciplinary team structure.
• Documents effectively and timely to support optimal communication, reimbursement, accreditation, and compliance.
• Promotes a team approach through cooperation, mutual respect, flexibility, and dependability.
• Remains open, sensitive, flexible, and ecumenical, using good judgment and sound reasoning.
• Participates in appropriate meetings and activities, including performance improvement.
• Demonstrates responsible stewardship of organizational resources, including self-care.
• Seeks personal growth and contributes to an atmosphere of excellence, respect, and caring.
• Reads relevant materials and attends in-services, seminars, or conventions for professional growth.
• Assists with orientation of new employees or volunteers as assigned.
• Performs other duties as assigned.

Benefits

• Generous paid time off package (4 weeks of vacation time, 2 weeks of sick time, 3 personal days, and 8 paid holidays)
• Medical, Dental, and Vision - paid 100% for employee only; competitive plan cost for dependents
• Health Savings Account (HSA) with matching employer contributions of up to $100 per month
• Company paid Long-Term Disability, Life and Accidental/Dismemberment, and Employee Assistance Programs
• Additional Life and Accident and Critical Illness, FSA/Dependent Care, Short-Term Disability, and other voluntary benefits are available
• 403(B) Retirement Savings Plan with company match up to 5%
• Mileage reimbursement
• End of year gift
• Tuition Assistance

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level