Hospice Transitions RN

Memorial Health•Springfield, IL

2d•$33 - $53

About The Position

The Hospice Transitions RN , as a member of the Advanced Care Management department, identifies, assesses, and prepares hospitalized patients and their loved ones for the transition to end-of- care. Coordinates the discharge plan, problem solves, and documents actions and plans while collaborating, consulting, and advocating on the patient’s behalf. Holding continuity of care as a priority, communicates and coordinates with the larger healthcare team including the hospitalist, nurse, patient care facilitator, social worker, and palliative care. Receives and follows up on hospice referrals by meeting with the patient/family, introducing hospice services, evaluating the patient’s status, eliciting choice for post-acute providers, facilitating orders, and anticipating needs for equipment, medication, and transportation.

Requirements

Graduate of an accredited College of Nursing, with a Bachelor’s degree required.
Current licensure as a Registered Nurse in the State of Illinois required.
Minimum three (3) years in nursing experience required.
One (1) year experience in hospice or palliative care required.
Must have clinical knowledge and critical thinking ability to create a viable and effective patient transition plan an identify barriers in service, effectively conduct verbal and written patient assessments, carry out the referral processes, and coordinate with other individuals involved in the plan of care.
Understanding of home hospice services and regulations.
Knowledgeable about disease states and prognosis and how illness progresses clinically and functionally.
Self-starter with a high degree of initiative
Ability to work as part of a team as well as form harmonious working relationships with post-acute providers
Excellent collaborative and problem solving skills
Excellent organizational skills
Excellent interpersonal and communication skills
Strong commitment to teamwork and patient experience

Nice To Haves

Experience in acute-care hospital setting; knowledge of discharge planning/case management preferred.

Responsibilities

Identifies, assesses, and prepares patients (and their families) for transition to home hospice care
Reviews hospital plan of care and current discharge planning efforts
Gathers additional information from the patient/family interviews, medical record, physicians, and other healthcare providers
Understands current and future disease states and can accurately match patient’s needs to appropriate level of service
Formulates a transition plan after reviewing available/appropriate care options and obtaining input from the patient/family, and the physician, healthcare team, and post-acute care providers
Identifies patient’s person-centered goals-of-care and provides education to the patient and family about home hospice’s line of services that would help meet those goals
If needed, for hospice patients receiving General Inpatient Level of Care, assist with admissions and daily visits when directed, coordinate with the hospice Interdisciplinary team
Maintain accurate daily documentation including patient assessments, plans, interventions, patient/family involvement, coordination with physicians, colleagues, and post-acute care providers
Coordinates care, problem solves, and documents actions and plans
Utilizes professional judgment to determine the need for a family meeting, escalation to leader, and other problem solving measures
Monitors transition plan and intervenes in an appropriate and timely manner with difficulties arise
Identifies, communicates, and creatively develops efficient delivery of care as the patient moves to home hospice services
Enters referral information and documents interactions in the appropriate electronic medical record
Collaborates, consults, and advocates
Develops and maintains positive, productive relationships with colleagues
Provides educational opportunities in hospital, collaborating with peers and palliative care team as appropriate
Actively participates in rounds with other team members to effectively coordinate and facilitate transition plan
Adheres to departmental and organizational protocols, policies and procedures, and supports operational and strategic plans and objectives
Demonstrates competencies related to service line knowledge, edibility criteria, regulations, and processes
Adapts to changes in the work environment or work process in a timely, positive, and effective manner
Demonstrates a commitment to teamwork by willingly accepting responsibilities and performing assignments that support the team
Completes all annual competency validation requirements
Actively participates in department meetings and operations
Identifies new systems or processes, protocol, and/or methods to improve practices
Maintains confidentiality of patient information
Demonstrates knowledge of appropriate utilization of internal and externa resources to meet patients’ needs
Ensures quality standards are met.
Follows all applicable licensure regulations and commonly accepted professional standards of practice
Utilizes time well to ensure follow-up is completed and needs of patient/family or healthcare providers are anticipated and proper plans are executed.
Performs other related work as required or requested.