Under the direction of the Home Care Services Director and Clinical Manager, the Inpatient Hospice Coordinator works in-patient with the Palliative Care Team, Hospital Case Managers and Hospitalists to ensure that patients who are identified as Hospice patients are consulted on and referrals are made, after giving patient the choice, to the appropriate Home Care Agency. This will be accomplished through attending MDT rounds on all acute floors and Transitional Care Unit and through an order by the physician in charge of the patient.
1. Provides inpatient consultation services and overall coordination of identified/referred Hospice patients.
a. Assists hospital staff in identification of appropriate Hospice patients.
b. Reviews medical record, communicates with the referring physician regarding the patient's case and patient and family wishes.
c. Participates in the Multidisciplinary rounds on ICU, PCU, MOU, SOU and the Transitional Care Units.
d. Performs comprehensive hospice evaluation of patient and assists with the clarification of patient home care needs.
e. Performs daily rounds on current and identified Hospice patients.
f. Documents patient's current status / wishes / home care agency choice in the patient's EMR.
g. Coordinates timely visits by calling all referrals to Intake Referral Coordinators of Home Health and Hospice agencies.
h. Provides care with a team approach that includes patient and family as integral and essential members of the care team.
i. Attends weekly IDG.
2. Assists in all facets of care coordination for Hospice referrals, i.e., working with Case Management staff on placement, ordering medication and durable medical equipment, and assisting with arranging transportation to an outside facility or home if necessary.
a. Performs admissions at hospital for General Inpatient patients and assists with symptom management. Determines if the patient is able to return home and make appropriate referral and arrangements. Performs daily visits to any Hospice patients in General Inpatient status to ensure care needs of patient and family are being met. Documents in hospital and HCS EMR.
3. Prepares and maintains accurate patient records and documents to support Hospice needs in the community.
a. Consults on out of area Hospice patients as requested.
b. Assists with discharge planning to home or other facility and notifies Hospice agency of pending referral.
c. Follows all current Hospice patients admitted to CWH and assists with discharge planning as appropriate.
4. Provides training and education for Hospital staff on Hospice Services.
5. During each patient visit, identifies need for other services and makes appropriate internal and community referrals, as evidenced by documentation in the patient's clinical record.
6. Collects and maintains a database to evaluate the quality of the Inpatient Hospice Coordinator program. Is actively involved in quality improvement process.
a. Maintains a database of all hospital re-admissions within 30 days of current Home Health patients and sends that report to the Director of Home Care Services.
7. Assesses for patient and family knowledge and questions. Refers to appropriate resources for additional information and support. Provides anticipatory guidance about illness, treatment, possible outcomes and health system issues.
8. Other duties as assigned.
Demonstrate Standards of Behavior and adhere to the Code of Conduct in all aspects of job performance at all times.
· Degree/Diploma from accredited school of nursing.
· At least 3 years recent successful experience as a registered nurse in Home Health and /or Hospice.
· Current state registration as a professional nurse-RN.
· CPR Certification.
· Current valid driver's license; availability of auto in good working condition with current insurance and willingness to drive in all types of weather.
· Proficient competent clinical skills and the ability to exercise independent judgment as well as seek guidance when indicated.
· Effective teaching and communication skills.
· The ability to function autonomously in a non-structured environment.
· Critical thinking and multi-tasking skills.
· Emotional stability to function effectively in unpredictable situations.
· Must possess basic computer skills related to Windows navigation, mouse usage, keyboarding, email communication and password management.
· BSN preferred.