NURSE, PUBLIC HLTH-PALL/ONC

Job Summary:

Collaborates with members of the interdisciplinary Palliative Care Team to provide quality, cost-effective clinical coordination/care management for the population of patients who meet the eligibility criteria for palliative care. This care can be provided in the inpatient, or clinic setting. Assists in the identification of patients who may benefit from palliative care and advocates for appropriate services. Assesses needs, develops and implements plans of care for patients transitioning across care settings. Acts as an expert consultant in symptom management and facilitates optimal end of life care through a team approach. Provides/facilitates ongoing education of staff regarding palliative care.

Essential Responsibilities:

• As a member of an interdisciplinary team assesses the physical, medical, psychological, social and spiritual needs of the patient and family to identify goals of care and develop a plan of care to provide coordinated care that emphasizes supportive services. Collaborates with discharge planners, physicians, Clinic and CCS staff, and patients/families to identify appropriate program/services and plan for transitions of care when needed. Arranges and participates as a member of the health care team in case/family conferences and consults as appropriate. Develops and maintains effective relationships with all key stakeholders necessary for the success of both the individual case and the program. Provides patient care/consultation utilizing systems assessment, evidence standards and practice related to palliative care. Functions as an expert clinician/role model in assessment of patient needs, development of a plan of care and evaluation of outcomes for this specific patient population. Facilitate end of life goal setting with patients and families. Collaborates with facility staff to assist with discharge planning when needed.
• Provide support and education to family and staff when death occurs in the inpatient setting. Assures that patient/family receive right care at the right time so that quality and utilization are simultaneously enhanced.
• Provides education and program development functions, including: Participates in orientation and ongoing CCS and volunteer education regarding transition of patients across care settings. Provides leadership in planning with CCS personnel to develop and implement policies and procedures related to patient transfers across care settings. Collaborates and communicates with CCS and Care Coordinator staff to assure provision of appropriate, timely care to patients in the home setting. Collaborates with others in the interdisciplinary healthcare team to assure that regulatory and compliance standards are met. Participates in quality and utilization management activities. Participates in professional committees/task forces as needed/requested. Performs other duties as requested. Assures professional competency through maintaining state-of-the-art skills and knowledge consistent with Medicare and JCAHO regulations, applicable nurse practice acts and agency policies.