Reports to Director of Inpatient Services. Possesses inâ€‘depth knowledge, competencies, and skills in the care of the seriously ill and palliative care. Assures that patients care is well coordinated as inpatient and through transitions to postâ€‘acute settings. Acts as liaison between palliative care team and others. Requirements: 3 to 5 years of directly related experience BSN Registered Nurse â€‘ NH or Other Compact State EMR/Practice Mgmt. software Palliative Care certification preferred or work toward certification within 2 years Responsibilities: Ensures timely patient triage and consults. For appropriate patients, provides initial patient contact, introduction to palliative care, and rounds on patients to follow up. Performs clinical assessment of patients as needed and documents in EMR and quality tracking system as appropriate. Communicates and collaborates with the interdisciplinary team on the patients plan of care. Provides patient education. Provides patient follow up post consult to assure patient needs are met. Assesses and updates patient education and marketing materials. Facilitates documentation of patient advance directives. Assures that goals of care documentation accurately reflects patients wishes and is communicated to postâ€‘acute agency when applicable. Acts as primary liaison between Palliative care team and other disciplines/departments/facilities. Communicates with postâ€‘acute receiving agency to ensure clear transition of care plan as applicable. Monitors effectiveness of liaison function for improved communication and care coordination. May follow up with postâ€‘acute patients after discharge, as needed. Evaluates and reports quality of transitions of care to postâ€‘acute agencies to support palliative care quality metrics. Identifies trends or barriers that reduce optimal care and makes recommendations for improvement. May lead / facilitate improvement initiatives. Supports liaison role with outpatient cancer center for patients who are admitted to hospital. Leads development and maintenance of quality monitoring system. Performs clinical data tracking, reporting and analysis. Delegates quality monitoring tasks appropriately to administrative support staff. Collaborates with nursing leadership to identify palliative care nursing education needs. Leads development of hospital staff (RN) education to increase the primary palliative care competencies. Serves as mentor to designated staff learners interested in palliative care certification.
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