Transitional Care Nurse Springfield
The Transitional Care Nurse will act as a liaison and educator to patient and families regarding the principles of hospice and end of life care options. The Transitional Care Nurse is responsible for coordinating the seamless transfer of high risk, hospice eligible patients from the hospital care setting to wherever they call home, as well as providing direct patient care to inpatient hospice patients.A Transitional Care Nurse with our Care Navigation Department is responsible for the following daily tasks and is not limited to...
- Coordinates the care transition of the patient including gathering chart information;
- Responsible for completing part or all the admission process for hospice eligible patients;
- Collaborates with referring and/or attending physician to ensure hospice eligibility;
- Collaborates with referring and/or attending physician to establish the Plan of Care;
- Provides daily GIP visit services or respite care when patient resides in the hospital;
- Maintains patient clinical records according to hospice and hospital policy;
- Assists in problem resolution with all personnel as well as families/patients/community;
- Provides consistency, predictability and visibility in the hospital setting;
- Act as liaison between patient, families, nursing staff, care coordinators, and physician staff to ensure quality care, symptom control, and emotional support for patients at end of life;
- Educate providers regarding symptom management tools, comfort order entry, inpatient hospice qualifications and enrollment;
- Partners with the sales team to establish and maintain positive working relationships with current and potential referral and payer sources to bring a greater understanding of the hospice philosophy and support patients and families that desire our care and are eligible;
- Assists in case management of patients outside of the hospital when requested;
- Participates in after hours on call schedule as assigned;
- Participates in Interdisciplinary team (IDT) meetings when necessary;
- Participates in the Quality Assessment Performance Improvement program;
- Maintains expert knowledge of available supports and services, based on client needs;
- Complies with Compliance Plan;
- Complies with HIPAA Policies. Maintains confidentiality of information relating to the patient and family. Will discuss only those aspects necessary to the care and treatment of patient and family with those directly involved in the patient’s care;
- As business needs may change, may perform additional responsibilities assigned by supervisor that are reasonably related to the position.
Registered nurse (RN) with current licensure in State of practice
- Minimum one (1) year experience in hospice
- Experience in care management, care coordination, discharge planning, etc. is preferred.