Job Description
- Responsible for continuity of care and discharge planning from inpatient facilities.
- Work with care management team to identify patients who may require Hospice & Palliative services.
- Serve as a liaison with physicians, inpatient nurses, case managers and care manager.
- Develop and maintain relationships with inpatient / outpatient institutions and contract nursing facilities.
- Respond promptly to requests for information and provide information regarding VNA’s hospice and palliative care program to patients, families, physicians and other sources of referrals in a manner that does not delay hospice services.
- Screen and process inquiries for admission to Hospice & Palliative Care services.
- Determine patient’s appropriateness for service consistent with VNA policies and admission criteria and in conjunction with the patient’s physician.
- Assist with implementation and coordination of services required for discharged patients from inpatient services.
- Plan for admission to VNA in coordination with Team Manager/PCC.
- Inform the Team Manager/PCC of unusual or potentially problematic patient/ family issues.
- Responsible for assessment, planning and coordination for nursing home admissions.
- Supervise the planning, implementation and delivery of direct clinical services to nursing home residents.
- Work with nursing home staff to provide care as needed.
- Maintain regular communication with attending physician, nursing home director and other nursing home staff concerning patient/family care needs in response to interventions.
- Assist in case conferences and family meetings at hospitals and nursing facilities as appropriate.
- Provide end of life educational programs/in-services to providers.
- Develop ongoing relationship with referral sources, including physicians, to keep them informed of agency programs and to solicit feedback regarding services provided by the agency.
- Attend IDT meetings as needed.
Other duties as assigned.
- Successful passage of VNA pre-hire medication test
- Current RN license in Mass.
- Minimum two (2) years RN experience required, five (5) years with one (1) year as a Hospice RN preferred.
