About The Position

Palliative Care at Home provides home-based palliative symptom assessment, treatment, and ongoing goals-of-care discussions for patients and families facing advanced illness. The interdisciplinary clinical team includes community health workers, nurse practitioners, nurses, social workers, and physicians, and works with patients’ healthcare teams to deliver evidence-based complex palliative and chronic care management. The program aims to improve symptoms and quality of life, reduce caregiver burden and unnecessary inpatient utilization, and facilitate hospice care when appropriate. The nurse provides evidence-based complex chronic care management and palliative care in patients’ homes. The role includes assessing and addressing patients’ and families’ needs, supporting medical management, treating complex symptoms, coordinating care, and engaging patients and caregivers in discussions about goals of care and treatment planning.

Requirements

  • Graduate from an accredited nursing program.
  • Bachelor’s degree in Nursing (BSN), or an Associate’s degree in Nursing (ADN) with current matriculation in a BSN program and an expected graduation date within the year.
  • An ADN-prepared RN with nursing experience requires approval by the CNO.
  • Relevant clinical competence in the assigned area of nursing practice; new graduates must have current knowledge of the nursing process and its application.
  • Current registration as a registered nurse in New York State.
  • Basic Life Support (BLS/BCLS) certification issued by the American Heart Association.
  • At least 2 years of experience managing patients with medically complex and chronic or severe illness.
  • Experience working in interdisciplinary care teams.

Nice To Haves

  • Bachelor’s degree in Nursing.
  • Palliative care or hospice experience.
  • CPR/ACLS certification.
  • Spanish-speaking proficiency or fluency.

Responsibilities

  • Work as a member of an interdisciplinary team to assess and address the complex care needs of patients and families facing serious illness.
  • Visit a caseload of patients and families in their homes to complete guided assessments, support medical management, address complex symptoms, and coordinate care.
  • Provide supportive individual and family counseling to reduce anxiety, stress, and symptoms precipitated by advanced illness and hospitalizations.
  • Engage patients and caregivers in goals-of-care discussions, review advance directives, and collaboratively develop treatment plans based on their goals.
  • Monitor and coordinate care plans in conjunction with the rest of the clinical care team.
  • Evaluate medical needs for a caseload of patients and provide direct in-home care.
  • Facilitate remote visits by providers as needed.
  • Communicate plans of care to consulting clinicians and the Palliative Care at Home interdisciplinary teams.
  • Educate patients and families about illness trajectory and medication use, and assess their understanding of the disease.
  • Participate in weekly interdisciplinary team meetings with the care team.
  • Complete required documentation.
  • Perform other related duties as assigned.
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