Hospice Transitional Nurse Liaison (HNS Legacy Hospitals)

Graham Healthcare Group•Northbrook, IL

1d•Hybrid

About The Position

SUMMARY Maintain a number of responsibilities for the ongoing daily operation of the Agency. Serve as the primary interface to the Agency’s referral sources such as physicians, Hospital SWs and discharge planners, hospital RNs, and all staff in the acute care setting. Obtain complete and accurate information from the patient medical records upon request for our hospice services. Ensure a safe transition from one level of care to another. Gather and share complete information on these complex patients.

Requirements

Associate degree from an accredited School of Nursing
A minimum of two (2) years of experience working as a Registered Nurse including acute care or oncology experience, hospice experience preferred
Experience with technologies such as Microsoft Office Suite, EPIC, and HCHB preferred
Able to meet the physical demands of providing nursing care, ambulating patients, transferring patients, assisting with exercises, etc.
Able to transfer patients as needed according to proper techniques of body mechanics to promote patient and staff safety
Able to use good and sound clinical judgment
Able to document accurately and appropriately
Hold, in good standing, a license as a Registered Nurse
CPR certified
Empathetic, non-judgmental, tactful, responsible, and organized
Understand the team approach and be a supportive team member

Nice To Haves

hospice experience preferred
Experience with technologies such as Microsoft Office Suite, EPIC, and HCHB preferred

Responsibilities

Complete an initial, comprehensive, and ongoing assessment of patient and family to determine hospice needs, including a complete physical assessment and history of current and previous illness(es)
Obtain complete/accurate demographic information and medical history, including diagnosis for care and primary care physician information
Introduce the Agency to the patient/caregiver, explain scope of our services and skilled services requested, and coordinate start-of-care visit
Order requested DME, supplies, and medications related to hospice care
Deliver community education as requested for assisted living facilities, skilled nursing facilities, and hospitals
Provide patient education at bedside regarding hospice, disease progression, and end-of-life care
Attend discharge planning meeting as requested, working with the facility team to provide a safe and successful discharge home
Determine hospice eligibility and appropriate level of care
Communicate with the clinical team on all complex, chronically ill patients, assisting staff and referral sources to prevent re-hospitalizations
Use Liaison Coordination note to communicate information
Assist in obtaining regulatory documentation as required
Provide professional nursing care by utilizing all elements of nursing process
Regularly re-evaluate patient and family/caregiver needs
Initiate the plan of care and make necessary revisions as patient status and needs change
Uses health assessment data to determine nursing diagnosis
Develop a care plan that establishes goals based on nursing diagnosis and incorporates palliative nursing actions; include the patient and family in the planning process
Counsel the patient and family in meeting nursing and related needs
Provide health care instructions to the patient as appropriate per assessment and plan
Complete, maintain, and submit accurate and relevant clinical notes regarding patient condition and care given
Record pain/symptom management changes/outcomes as appropriate
Communicate with the physician regarding the patient's needs and report changes in the patient's condition; obtains/receives physicians' orders as required
Communicate with community health-related persons to coordinate the care plan
Teach the patient and family/caregiver self-care techniques as appropriate
Provide medication, diet, and other instructions as ordered by the physician and recognize and utilize opportunities for health counseling with patients and families/caregivers
Work in concert with the interdisciplinary group
Provide and maintains a safe environment for the patient
Assist the patient and family/caregiver and other team members in providing continuity of care
Follow up as needed and appropriately with doctor's office and clinical and management staff pertaining to any concerns regarding patient care
Participate in on-call duties as defined by the on-call policy
Supervise ancillary personnel and delegate responsibilities when required
Assume responsibility for personal growth and development and maintain and upgrade professional knowledge and practice skills through attendance and participation in continuing education and in-service classes
Actively participate in quality assessment performance improvement teams and activities
Prepare and maintain clinical documentation according to Agency policies and acceptable nursing standards
Act as a Customer Service Liaison between the company and GIP facilities
Comply with Company’s Core Values and Core Competencies
Perform other duties as assigned by supervisor