AIC Transition Nurse (RN)
9 days ago
Providence
Job Description About this position as a AIC Transition RN The Advanced Illness Care Transition Nurse ( AIC Transition RN) is an office-based position that provides several critical functions on the Advanced Illness Team, HopeHealth’s community based palliative care team that provides care to patients and families with serious illness living in assisted livings, homes and nursing homes. This position reports to the Senior Manager for Community Based Palliative Care and works in a highly collaborative nature with AIC team, leaders and other departments at HopeHealth as well as referring entities such as hospitals, primary care and specialty clinics and long term care and assisted living facilities. The AIC Transition RN ensures seamless transitions of care on and off the program. This role also serves as the primary clinical resource for much of the team’s communication and liaisons with patients, families, internal HopeHealth Departments and referring entities to ensure safe, efficient and coordinated delivery of care. This role takes primary responsibility for reviewing all referrals to Advanced Illness Care accepting those patients who meet the eligibility guideline and reaching out to referral sources when patients do not qualify based on information received. At times, this role contacts referral sources or family members, seeking additional information to determine eligibility when required, possessing assurance in explaining their decisions to patients, families, referring entities and internal and external stakeholders. The AIC Transition Nurse serves as the clinical communication hub of a busy community-based palliative care consult service. Incoming calls of a clinical nature will be escalated to this role from administrative resources. This role must have a high degree of comfort in assessing and addressing clinical concerns or questions from referring entities, patients and families over the phone. Comfort with navigating care with clinics, hospitals, LTC and ALFs and communicating effectively with referring providers is essential. Knowledge of HopeHealth’s strategic partners and their needs are paramount in positioning HopeHealth’s AIC as the community based provider of choice. . AIC clinicians often require assistance in reaching offices of referring entities and this role assist with that care coordination. Because this role is intimately involved in AIC patients care, AIC Transition Nurse may be the first to observe concerns about care delivery and will escalate these immediately to AIC leaders. This role maintains positive and effective working relationships with other departments at HopeHealth and often serves as first point of contact for AIC team with Access Center, other palliative and hospice teams at HopeHealth, Care Navigation Teams among others, seeking effective transitions and assuring continuity of care wherever possible. All of this communication requires strong critical thinking skills and diplomacy and tact. When patients have been determined as eligible for hospice services, this role ensures seamless and coordinated transfer when families have chosen to continue care with HopeHealth. This includes working with the AIC team, the patient’s existing health care team, Access Center to ensure a safe transition. The AIC Transition Nurse is often the resource to assess and offer hospice as an option when families or referring entities call in distress. This person must have a strong knowledge around eligibility and have a high degree of comfort addressing this over the phone in a manner that creates safety, supports people potentially in crisis, and gets patients and families the “right care at the right time.” Exceedingly strong clinical skills, expertise with hospice care and hospice benefits, and a high degree of emotional intelligence are essential. In concert with other AIC leaders, this role takes part in a daily huddle to ensure clinician’s schedules are full and pending referrals are scheduled timely. When patients on service are admitted or seek care in an ED, the AIC Transition RN seeks to coordinate that care and provide timely follow-up with the AIC team upon return home. This role ensures that AIC patients who transfer to hospice are properly attributed as an internal referral. This is a full time 40 hour per week position with the hours of 8:00am-4:30pm Essential Duties • Deep understanding of the value of hospice and palliative care and committed to expanding access to these services to our community, “right care, right time”, • Providing education and support to referral sources, patients and families on hospice and palliative care including trajectory of illness and what to expect, • Responsible for accepting eligible patients onto program, obtaining additional information on referrals when needed to qualify patients and communicating with referring entities when patients are not accepted, • Provides hospice information telephonically and makes recommendations to patients and families and referral sources when this may be the best option, • Telephonic management of clinical issues from AIC patients and families, triaging and advising as appropriate and answering incoming calls when admin resources are not available, using the nursing process to assess and formulate a care plan in conjunction with other team members, • Expertise in palliative approach to care including management of common issues like pain, dyspnea, constipation, whole person care, • Aware of psychological and emotional aspects of care and caregiving, uses these to effectively engage and serve patients and families, • Assisting administrative resources with appropriate scheduling of patients based on clinical acuity, • Care coordination with referring entities, navigating clinic settings to meet their needs, and comfort managing relationships and concerns over the phone, • Care coordination with field-based AIC clinicians and AIC leaders, assisting team in delivering coordinated and high quality care, • Team player and key member of AIC IDT, • Collaboration with other HopeHealth departments, especially Access Center, palliative teams, hospice teams, Care Navigation teams to ensure smooth, timely transitions of care and continuity of care across settings, • Managing and Leveraging PING to ensure continuity of care, • Expertise in all aspects of hospice care- eligibility, benefits, related and not related meds, diagnoses and implications for AIC patients if and when transitions to hospice occur, • Proactive in addressing concerns or issues with clinical and operational aspects of AIC team’s delivery of care, • Responsible for seamless transitions when AIC patients elect hospice, working closely with referring entities and Access Center, • Proper tracking of AIC to hospice transitions, • Aware of key strategic partnerships and able to assist partner with info/feedback about mutual patients as well as providing education and information, • Positively contributes to all phases of the Quality Assessment Performance Improvement (QAPI) program. Contributions may include; identification of problem area recommendations to address problem areas; data collection; attendance at periodic QAPI meetings or participation in performance improvement projects., • Build trust and confidence with local providers and customers by promoting a positive image of the palliative care program, • Collaborates with other HopeHealth entities to ensure seamless patient transitions RN, BSN preferred 5 years experience with minimum of 2 years of hospice experience, BSN preferred CHPN certified or CHPN certification within one year of hire Strong active listening and critical thinking skills Current RN License Ma and RI High degree of emotional intelligence, diplomacy and tact Experience practice nursing over the phone preferred Comfort working in a fast-paced environment in and with large and complex organization(s) Strong listening and verbal skills Strong clinical assessment skills Experience working in multiple EHRs . LANGUAGE SKILLS Ability to read, analyze, and interpret common scientific and technical journals, financial reports, medical records and legal documents. Ability to respond to common inquiries or complaints from customers, regulatory agencies, or members of the business community. Ability to write professional correspondence and effectively present information to team, peers, management, and public groups. MATHEMATICAL SKILLS Ability to work with mathematical concepts such as probability and statistical inference. Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations. Ability to calculate medication dosages and apply principles of equianalgesia. REASONING ABILITY Ability to evaluate situations according to established standards and policies. In addition, ability to define problems, collect data, establish facts and draw valid conclusions. Ability to use knowledge of diseases and common trajectory to formulate prognosis, and make recommendations regarding future treatment with this in mind. COMPUTER SKILLS Must be able to proficiently use computer, cell phone. Ability to navigate and document clinical encounters in several EMRs. Knowledge and working ability of Microsoft Word, Outlook and Excel in a Windows environment. What are the job benefits? For your health and peace of mind: • Medical, dental and vision insurance, • Retirement plan with employer contribution, • Pre-tax flexible spending account for healthcare and dependent care, • Disability coverage, • Discounts on voluntary insurance programs, • Life and long-term-disability insurance, • Paid time off (PTO) and paid holidays, • A robust orientation programs, • Educational assistance, • Reimbursement for certifications, • HopeHealth Clinical Education Lab (continuing education) Discover a career that transforms lives – including yours. At HopeHealth, health care is more than a career choice. It’s a calling. You can see it in our incredible team, who are as compassionate as they are talented. You can see it in the trust that our patients and families place in us every day. And you can see it in our values – as a health care organization, and as an employer. At HopeHealth, we care deeply about every life we touch, including yours. We’re committed to giving employees the support they need to not only excel at their jobs, but to love what they do. Join us, and you’ll be part of a team that inspires you, a workplace that invests in you, and a mission that brings hope and dignity to patients and families every day. HopeHealth is a not-for-profit market leader in the areas of home health, palliative and hospice care serving Massachusetts and Rhode Island. Our Hospice Care Team HopeHealth’s hospice care team provides comfort and support to patients who are in the advanced stages of serious illness or nearing the end of life. Join our team, and you’ll: • Help patients and families make every moment count. Hospice is a special calling. Your work will help patients live as comfortably and fully as possible, and provide meaningful support for everyone in the family. As part of our team, you’ll provide patients, and their loved ones, with a peaceful end-of-life setting., • Know that your expertise and unique perspective are valued. In our inclusive work culture, you’ll be free to work autonomously while feeling authentic support from your team. You’ll experience the mutual respect, collaboration and trust of a healthcare team that’s committed to going above and beyond for every patient – and for every member of the team., • Enjoy a flexible work schedule and generous benefits. Work full-time, part-time or per diem with scheduling flexibility to maximize your work/family life balance. Benefits include competitive compensation package, health care coverage, education reimbursement, and an employer-match retirement plan., • Be part of a leading team. For over 40 years, HopeHealth Hospice has set the gold standard for end-of-life care. We’re the second-oldest hospice in the country, and one of the largest not-for-profit hospice providers in New England. We are committed to giving all of our employees the skills and support they need to deliver the best possible patient care. HopeHealth is an Equal Opportunity Employer Our Commitment to Diversity, Equity and Inclusion HopeHealth is committed to advancing diversity, equity and inclusion in the workspace. We believe that attracting, developing and empowering exceptional people will allow us to continue to deliver the best care for our patients and families. All qualified individuals – inclusive of race, color, religion, sex, gender, sexual orientation, national origin, age and ability – are warmly welcome at HopeHealth. 8:00am-4:30pm 40
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