Hebrew SeniorLife - Dedham, MA

posted 2 months ago

Full-time - Mid Level
Dedham, MA
Hospitals

About the position

The Community Based Palliative Care Transition Care Coordinator (PTCC) is a professional nursing role responsible for coordinating care for patients with progressive illnesses. This position involves collaboration with patients, families, and healthcare providers to ensure effective transitions across various care settings, including acute care, home health, and hospice. The PTCC aims to support patients and families through their care journey, focusing on their treatment preferences and goals of care.

Responsibilities

  • Assess the patient's and family caregiver's needs and coordinate appropriate services such as DME, home health care, and hospice.
  • Develop a plan of care in collaboration with the palliative care APN based on the treatment plan.
  • Assist in all facets of care coordination for referrals.
  • Provide disease management instruction and education to patients and their families.
  • Provide clinical guidance to facility staff regarding patient care issues, assessments, and interventions.
  • Participate with the interdisciplinary team in various care settings to enhance communication and coordination of services.
  • Obtain necessary medical information regarding the patient's health status and goals of care and document in EMR.
  • Act as a resource to coordinate complex cases for safe transitions to other care settings.
  • Attend required meetings to improve team communication and quality of care.
  • Coordinate additional services with other palliative care team members to assist clients and families during transitions.
  • Review policies and services with referred patients and obtain consent for medical care.
  • Communicate essential patient information to care setting clinicians initiating care.
  • Provide training and continuing education for staff.
  • Assist in the development of clinical practice guidelines and standards for quality care.
  • Employ metrics and data tracking of census and referrals.
  • Assist with obtaining physician orders as required.
  • Respond to inquiries regarding care services and programs.

Requirements

  • Valid nursing (RN/LPN) License in the State in which service is provided.
  • Minimum of 3 years nursing experience preferred.
  • Minimum of 3-5 years of experience with home health, hospice/palliative care strongly preferred.
  • Advanced certification in hospice and palliative nursing care (CHPN/CHPLN) preferred.

Nice-to-haves

  • Experience in care coordination and interdisciplinary team collaboration.
  • Strong communication and problem-solving skills.
  • Ability to work under stressful circumstances.

Benefits

  • Health insurance coverage
  • Paid time off
  • Continuing education support
  • Flexible scheduling options
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