Palliative Care Nurse - Community Based

Alive•Nashville, TN

154d•Hybrid

About The Position

The Palliative Care Nurse serves as the nurse case manager for a geriatric and palliative care population providing primary and chronic care management, primarily coordinating care with the patient and patient caregivers from enrollment through discharge of services. This care delivery may take place via telephone, in-home/facility visits and/or telehealth services. The Palliative Care Nurse utilizes the nursing process and Alive’s visit standards to provide safe, supportive and effective care management. Care provided should be within nursing scope of practice and aligned with the patient’s goals, throughout the disease process, including symptom management, education, and psychosocial support which may include appropriately utilizing resources of social work or chaplaincy as needed. Due to the variety of variables that may impact navigation of care for this population, flexibility, organization, and building rapport rapidly with patients and their caregivers is highly valued. The Palliative Care Nurse will be accountable for meeting Alive Care Standards and collaborating effectively with Alive team members as appropriate.

Requirements

Current nursing license (Registered Nurse or Licensed Practical Nurse)
Minimum one-year nursing practice or equivalent experience required.
Current Tennessee RN License or compact license.
If required to drive to carry out the duties of this position: current driver's license and automobile insurance as required by Tennessee State Law.

Nice To Haves

BSN preferred.
Knowledge of or willingness to learn serious illness care including hospice and palliative care.
Hospice, Palliative Care, Geriatrics, Medical Surgical, or Home Health and/or long-term care preferred.

Responsibilities

Utilizes critical thinking skills and nursing process to holistically assess patient and family, develop and implement a plan of care that aligns with patient’s goals, including utilization of IDT resources.
Educate family/caregiver(s) regarding plan of care, interventions, diagnosis and prognosis, medications, use, administration and side effects, how to provide care, use of equipment and supplies and how to contact Alive for assistance.
Completes documentation of patient visit same day and documenting accurate reflection of patient’s care; updates plan of care same day or more timely if indicated.
Concludes patient visit by providing encouragement to patient and caregiver(s), ensuring use of emergency phone number (Call Center Number) and anticipatory needs prior to next visit have been met. Engages in active listening and expresses gratitude before leaving home.
Follows up on messages to team members as needed, synchronizes iPad, and spiritual release of the visit.
Demonstrates effective communication skills and acts a liaison between Alive and the patient’s primary geriatric - palliative provider or other medical providers involved in the patient’s care.
Communicates and collaborates with providers, medical directors, outside facilities and other health care providers regarding patient assessment and response to plan of care.
Notifies appropriate staff of status changes per Alive procedure and collaborates with team members to assure appropriate, empathetic and effective patient/care giver support and care.
Reports unusual and problematic patient/care giver issues to appropriate supervisor, and other IDT members as appropriate.
Timely completion of work: performance evaluations, annual competencies, continuing education requirements, contact hours.
Appropriate and timely documentation of mileage; accurate and cost-effective medical supply utilization.
Assists the organization in achieving excellence in publicly reported quality scores as well as internal measurements of success.
Adheres to Joint Commission and State healthcare laws.
Arrives on time for interdisciplinary team meetings and is financially responsible with Alive resources.