Hospice Care Transition Nurse

ProCare Hospice of Nevada•Paradise, NV

23d

About The Position

Job Summary: The Care Transition Nurse (CTN) serves as the primary coordinator for hospital-based hospice and palliative care. The CTN manages all hospice and palliative care referrals, facilitates admissions to hospice or palliative consultative services, and interfaces with patients, families, and attending physicians. They triage incoming referrals and coordinate interdisciplinary team (IDT) members to address patients' immediate needs effectively. In collaboration with the hospice and palliative care medical consultant (when applicable), the CTN initiates care plans and discharge planning while communicating patient goals and treatment plans with the IDT. The CTN conducts nursing assessments, exercises clinical judgment, and makes treatment decisions based on patient and family needs, in accordance with professional nursing standards. Additionally, the CTN promotes ProCare Hospice Services—including hospice, palliative care, and pediatrics—through collaborative relationships with acute care facilities and by providing professional development opportunities and community education. Accountability: Reports to the Director of Business Development and the Director of Nursing

Requirements

At least one year of experience in a comparable setting/unit
A degree in nursing from an accredited program is required; BSN preferred
Licensure for nursing practice in Nevada or compact state licensure as applicable
Proficient in nursing assessments, including physical exams and psychosocial evaluations
Ability to recommend evidence-based best practices
Demonstrates excellent oral and written communication skills
Strong organizational skill, with the ability to manage multiple tasks and meet deadlines
Exceptional interpersonal skills, working both independently and collaboratively
Must have reliable transportation, a valid driver’s license, and current auto insurance
Successful completion of background check pursuant to NRS 449.188 and NRS 179A.100, verification of professional/personal references, previous employment, and motor vehicle report (MVR) (may include education verification)
Must be able to read, speak, write, and understand the English language
Proficient in-patient health information systems, Microsoft Office, and internet browsers
Must be able to handle frequent interruptions, problem-solve and have excellent follow- through skills
Ability to work in a fast-paced environment with tact and diplomacy
Skilled in conflict resolution and management
Maintains a positive public image for ProCare Hospice through respectful and open communication
Willing to drive long distances under tight schedules, as required
Must be able to cope with emotionally charged situations encompassing patients, families, and other caregivers

Nice To Haves

Hospice and/or palliative care experience is strongly preferred

Responsibilities

Conduct initial and ongoing assessments of the terminal diagnosis's impact on the patient’s physical, functional, psychological, and environmental needs
Implement and revise individualized care plans as needed, focusing on managing discomfort and symptom relief and utilizing specialized nursing skills for palliative and end-of-life care
Initiate appropriate preventive and rehabilitative nursing procedures
Prepare clinical and progress notes documenting progress toward goals
Employ a case management approach, referring to other services as needed
Determine the scope and frequency of services based on acuity and patient/family needs
Identify barriers to meeting patient/family needs and secure necessary resources
Complete nursing assessments and consult with the IDT to determine the appropriate service line (palliative or hospice care)
Develop care plans in collaboration with patients, families, physicians, and the IDT, identifying problems, goals, and interventions
Facilitate care transitions to home or other facilities as needed
Monitor treatments and medication use, ensuring optimal resource management
Procure discharge needs such as DME, medications, home care, and community services
Participate in quality improvement activities, the QAPI program, and hospice in-service training
Refer ProCare Hospice deaths during hospitalization to Bereavement Services for follow-up
Evaluate personal support needs and utilize available systems
Pursue professional growth through continuing education and evidence-based practice
Crosstrain as needed to meet organizational needs, including admissions, inpatient units, triage, and home care case management
Participate in in-service programs
Apply specific criteria for hospice admission and re-certification to ensure appropriate care levels
Contribute to performance improvement programs
Treat and write orders for hospice patients, if permitted by state regulations
Collaborate with acute care IDTs and ProCare Hospice Programs to provide quality end-of-life care
Assess care options based on referrals and secure ProCare Hospice referrals
Obtain written referrals and consent documentation
Confirm insurance coverage and hospice benefits
Manage census generation and daily coordination of facility activities, communicating updates to relevant team members
Ensure timely documentation to meet regulatory and facility standards, promoting accurate communication within the team
Maintain knowledge of federal, state and CHAPS regulatory hospice standards, laws, and Conditions of Participation
Demonstrate effective time management skills by coordinating activities to achieve maximum, productivity and efficiency, willingness to adjust or revise work schedules as requested, seeking prior authorization for overtime, adhering to the policy for make-up time, completing assigned projects within specified time frames
Identify opportunities for performance improvement
Maintain professional appearance consistent with ProCare Hospice of Nevada dress code policy
Support department heads with ongoing staff orientation on documentation policies and procedures
Participate in the development of companywide educational materials