Advanced Care Planning- RN

Avera•Sioux Falls, SD

2d•Onsite

About The Position

Provides skilled, patient-centered care coordination and clinical support for patients with complex, chronic, serious, or advanced illness needs. Works collaboratively with patients, families, providers, social workers, care management teams, and other interdisciplinary care team members to coordinate timely, appropriate care aligned with patients’ goals, values, and treatment preferences. Collaborates with the Avera Medical Group population health team to identify patients who may benefit from Advanced Care Planning services.

Requirements

Active Registered Nurse (RN) license in the state of practice.
Advance Care Curriculum Certification – Respecting Choices, to be obtained within 180 days of hire.
Clinical nursing experience; experience in care coordination, case management, chronic disease management, hospital, primary care, oncology, hospice, palliative care, geriatrics, or another setting involving complex patient needs is preferred.
Experience with goals-of-care conversations, Advance Care Planning, palliative care, or hospice.
Experience working within an interdisciplinary care model.
Ability to work the specified hours.
Visual acuity adequate to perform position duties and ability to communicate effectively, hear, understand, and distinguish speech and other sounds.
Ability to perform essential job functions satisfactorily; reasonable accommodations may be made where they do not cause undue hardship.
Ability to maintain confidentiality and work effectively in a team environment.

Nice To Haves

Bachelor’s degree in nursing.
Clinical nursing experience in care coordination, case management, chronic disease management, hospital, primary care, oncology, hospice, palliative care, geriatrics, or another setting involving complex patient needs.

Responsibilities

Conduct comprehensive nursing assessments and identify patients who may benefit from Advance Care Planning services, including people with chronic or serious illness, advanced age, multiple hospitalizations, or complex healthcare needs.
Prepare patients and families for Advance Care Planning discussions about healthcare goals, values, preferences, and future medical decisions, helping them understand treatment options and make informed decisions.
Educate patients and families about advance directives, healthcare power of attorney, living wills, POLST forms, and other Advance Care Planning documents.
Serve as a consistent clinical contact and advocate for patients and families throughout the care pathway.
Promote documentation of patient wishes in the electronic medical record and ensure documents are accessible across care settings.
Work with IT to develop electronic medical record functionality for an Advance Care Planning care pathway, documentation standards, and outcome tracking.
Collaborate with providers, care managers, social workers, palliative care, Avera@Home, and interdisciplinary teams to identify patients who may benefit from Advance Care Planning services.
Collaborate with patients, families, providers, and community resources to align care plans with patient preferences and provide follow-up support after Advance Care Planning visits or discussions.
Coordinate referrals to palliative care, hospice, social services, behavioral health, spiritual care, community resources, and other support services as indicated.
Apply Avera’s mission, vision, core values, and social principles; promote compassion, hospitality, and stewardship.
Uphold Avera’s CARE standards, maintain confidentiality, work effectively in a team, and comply with applicable safety principles, laws, regulations, and standards.