Nurse Navigator Palliative BWH

Mass General Brigham•Boston, MA

5d•$42 - $106•Onsite

About The Position

The PALLIATIVE CARE RN NAVIGATOR for the inpatient consult service serves as a central coordinator in managing referrals, patient flow, and care transitions for patients with serious or complex illness. This role is responsible for receiving inpatient palliative care consult referrals from a variety of sources, including inpatient providers, outpatient clinics, and the emergency department, and collaborating with referring clinicians to obtain additional clinical and psychosocial information necessary to appropriately triage and prioritize referrals. Prioritization is based on symptom burden, acuity of illness, goals-of-care needs, and patient/family support requirements to ensure patients with the most urgent palliative care needs receive timely intervention. The RN Navigator facilitates communication and coordination among interdisciplinary teams and specialty services to promote continuity, consistency, and alignment of care plans across the continuum. The role may also include participation in interdisciplinary huddles with Emergency Department, Palliative Care, Case Management, and other clinical teams to assess patient appropriateness for established care pathways and program protocols. The RN Navigator educates clinicians and staff on pathway criteria, supports appropriate patient entry into designated programs, and monitors patient progression through the continuum of care to ensure timely placement into the next appropriate level of care or disposition setting. In collaboration with these clinical teams the RN Navigator gathers pertinent clinical and social information to determine the most appropriate service line, level of care, and care setting within the health system, helping to optimize patient flow, resource utilization, and patient-centered outcomes.

Requirements

Graduate of an approved school of nursing with current registration in Massachusetts required.
For newly licensed nurses a Bachelor of Science Degree in Nursing is required.
Registered Nurse in Massachusetts required.
Minimum of 3 years of nursing experience with complex care populations required.
Demonstrated ability to manage complex patient needs, prioritize referrals, and coordinate care across interdisciplinary teams.
Excellent communication, collaboration, and organizational skills required.
The RN must show evidence of the basic analytic thinking necessary to care for a group of patients.
Must demonstrate observational skills and the ability to set priorities.
Must be able to function under stress with good interpersonal and communication skills.
Must demonstrate effective skills in applying hospital standards in area of service, teamwork, communication, respect for others, and time/priority management.

Nice To Haves

Experience in palliative care.
Inpatient experience in oncology, geriatrics, or emergency medicine.
Prior experience in nurse navigation, care coordination, case management, or transitions of care.
Experience facilitating goals-of-care discussions, discharge planning, and resource coordination preferred.
Certification in palliative care or case management preferred.

Responsibilities

Accountable for assessing, planning, implementing and evaluating a plan of care for a specific patient assignment.
Sets priorities when organizing care for patients with varying acuity.
Maintain continuity through clear and concise (verbal and written) communication.
Demonstrates appropriate knowledge of growth and development of the adult and geriatric patient. In areas, such as the NICU and Obstetrics the principals of growth and development are applicable to the neonate.
Documents patient care in a manner that is clear, complete, concise and in compliance with nursing documentation standards.
Develops a comprehensive plan of care based on data from an initial assessment of patient and family, information from other members of the health care team, intra-agency referral and previous medical records.
Develops a comprehensive educational plan for the patient and family, utilizing appropriate resources and documents according to the department’s documentation standards.
Develops a comprehensive discharge plan utilizing appropriate resources and referrals including community resources.
Evaluates the effectiveness of the plan of care, and documents progress in meeting stated goals. Revises plan of care as needed to achieve desired outcomes.
Participates actively in the unit-based and organizational quality management and/or quality improvement programs.
Provides a safe environment for patients, staff, family and visitors.
Administers medication safely according to established policies and procedures.
Performs nursing procedures safely and efficiently.
Uses equipment safely and efficiently.
Demonstrates awareness of potential/actual risks of infection and modes of transmission.
Utilizes universal precautions in nursing practice.
Interacts with patients, families, and colleagues in a professional manner.
Collaborates with other discipline(s).
Develops, utilizes and evaluates unit-specific standards of care.
Upholds the A.N.A. code of ethics and acts as a role model to other staff members.
Participates in determining and implementing goals and objectives for the unit.
Participates in determining goals and objectives in the periodic review and evaluation.
Serves on unit-based and organizational committees and disseminates information to peers.
Assumes responsibility for personal and professional growth through identification of own learning needs.
Shares knowledge and experience with colleagues.
Participates in unit-based and organizational educational programs.
Seeks and accepts guidance for additional learning needs.
Utilizes nursing research findings in clinical practice.
Contributes to nursing and/or medical research endeavors by supporting investigators.
Utilizes time and materials in an effective and economical manner.
Provides suggestions which support the delivery of cost-effective health care.
Assesses patient's acuity accurately when making decisions regarding staffing, transfers and assignments.
Demonstrates awareness of the need to manage within established budgetary boundaries.
Participates in the orientation of new staff members, students and others as appropriate.
Provides input into the clinical evaluation of other staff, as appropriate.
Assumes responsibility for the unit in the absence of leadership personnel.
Adheres to hospital and nursing policies and aids in their interpretation to others.
Recommends change in policies and procedures through appropriate channels.
Participates in the cooperative effort and peer support required for the smooth running of the unit, e.g., flexibility in relation to patient assignments, shift assignment, or work schedule.