Hospice Care Transition Nurse in Enterprise, NV

Full-time

Description

Job Summary:

The Care Transition Nurse (CTN) serves as the primary coordinator for hospital-based hospice and palliative care. The CTN manages all hospice and palliative care referrals, facilitates admissions to hospice or palliative consultative services, and interfaces with patients, families, and attending physicians. They triage incoming referrals and coordinate interdisciplinary team (IDT) members to address patients' immediate needs effectively.

In collaboration with the hospice and palliative care medical consultant (when applicable), the CTN initiates care plans and discharge planning while communicating patient goals and treatment plans with the IDT. The CTN conducts nursing assessments, exercises clinical judgment, and makes treatment decisions based on patient and family needs, in accordance with professional nursing standards. Additionally, the CTN promotes ProCare Hospice Services—including hospice, palliative care, and pediatrics—through collaborative relationships with acute care facilities and by providing professional development opportunities and community education.

Accountability:

Reports to the Director of Business Development and the Director of Nursing

Requirements

Job Duties and Responsibilities:

In alignment with ProCare Hospice’s philosophy, objectives, and policies, the CTN performs the following essential functions:

Quality Provision of Services:
• Conduct initial and ongoing assessments of the terminal diagnosis's impact on the patient’s physical, functional, psychological, and environmental needs, including:
• Risks for pathological grief
• Cultural and spiritual considerations
• Verbal and non-verbal communication patterns

2. Implement and revise individualized care plans as needed, focusing on:
• Managing discomfort and symptom relief
• Utilizing specialized nursing skills for palliative and end-of-life care

3. Initiate appropriate preventive and rehabilitative nursing procedures

4. Prepare clinical and progress notes documenting progress toward goals

5. Employ a case management approach, referring to other services as needed

6. Determine the scope and frequency of services based on acuity and patient/family needs

7. Identify barriers to meeting patient/family needs and secure necessary resources

8. Complete nursing assessments and consult with the IDT to determine the appropriate service line (palliative or hospice care)

9. Develop care plans in collaboration with patients, families, physicians, and the IDT, identifying problems, goals, and interventions

10. Facilitate care transitions to home or other facilities as needed

11. Monitor treatments and medication use, ensuring optimal resource management

12. Procure discharge needs such as DME, medications, home care, and community services

13. Participate in quality improvement activities, the QAPI program, and hospice in-service training

14. Refer ProCare Hospice deaths during hospitalization to Bereavement Services for follow-up

15. Evaluate personal support needs and utilize available systems

16. Pursue professional growth through continuing education and evidence-based practice

17. Crosstrain as needed to meet organizational needs, including admissions, inpatient units, triage, and home care case management

18. Other duties as assigned

Organizational/Regulatory Compliance:
• Participate in in-service programs
• Evaluate and address personal support needs
• Apply specific criteria for hospice admission and re-certification to ensure appropriate care levels
• Contribute to performance improvement programs
• Treat and write orders for hospice patients, if permitted by state regulations
• Collaborate with acute care IDTs and ProCare Hospice Programs to provide quality end-of-life care
• Assess care options based on referrals and secure ProCare Hospice referrals
• Obtain written referrals and consent documentation
• Confirm insurance coverage and hospice benefits
• Manage census generation and daily coordination of facility activities, communicating updates to relevant team members
• Ensure timely documentation to meet regulatory and facility standards, promoting accurate communication within the team
• Other duties as assigned

General Responsibilities:
• Maintain knowledge of federal, state and CHAPS regulatory hospice standards, laws, and Conditions of Participation
• Demonstrate effective time management skills by coordinating activities to achieve maximum, productivity and efficiency, willingness to adjust or revise work schedules as requested, seeking prior authorization for overtime, adhering to the policy for make-up time, completing assigned projects within specified time frames
• Identify opportunities for performance improvement
• Maintain professional appearance consistent with ProCare Hospice of Nevada dress code policy
• Support department heads with ongoing staff orientation on documentation policies and procedures
• Participate in the development of companywide educational materials

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Physical/Safety Requirements:
• Comfortable providing physical care to patients; able to lift 10 to 40 lbs. occasionally
• Participates appropriately in emergency procedures (including disaster drills)
• Operates equipment in a safe manner and shares responsibility for communicating safety violations or unsafe practices to management
• Able to use general office equipment including telephone, copy machine, fax machine, computers, etc.
• Category 2 for potential exposure to blood/body fluids. (Does not usually require the performance of procedures or other tasks in the work routine that involve exposure to blood, body fluids or tissues, but Category 2 tasks may require the unexpected performance of these procedures)
• The noise level is minimal
• Utilizes appropriate PPE as needed
• Follows the designated plan of action in the event of a fire or other emergency/disaster
• Must be able to move intermittently throughout the workday
• Must have the strength and endurance required for sitting for lengthy periods of time
• Must possess sight/hearing, speech senses, or use prosthetics that will enable these senses to function adequately so that the requirements of this position are fully met
• Use appropriate body mechanics

The work environment and physical demand characteristics described here are representative of those an employee encounters while performing the essential functions of this job.

In compliance with the Americans with Disabilities Act of 1990, the employer will provide reasonable accommodations to meet the work environmental and physical demands listed above.

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Qualifications and Experience:
• At least one year of experience in a comparable setting/unit
• Hospice and/or palliative care experience is strongly preferred
• A degree in nursing from an accredited program is required; BSN preferred
• Licensure for nursing practice in Nevada or compact state licensure as applicable
• Proficient in nursing assessments, including physical exams and psychosocial evaluations
• Ability to recommend evidence-based best practices
• Demonstrates excellent oral and written communication skills
• Strong organizational skill, with the ability to manage multiple tasks and meet deadlines
• Exceptional interpersonal skills, working both independently and collaboratively
• Must have reliable transportation, a valid driver’s license, and current auto insurance
• Successful completion of background check pursuant to NRS 449.188 and NRS 179A.100, verification of professional/personal references, previous employment, and motor vehicle report (MVR) (may include education verification)
• Must be able to read, speak, write, and understand the English language
• Proficient in-patient health information systems, Microsoft Office, and internet browsers
• Must be able to handle frequent interruptions, problem-solve and have excellent follow- through skills

Mental/Emotional Skills:
• Ability to work in a fast-paced environment with tact and diplomacy
• Skilled in conflict resolution and management
• Maintains a positive public image for ProCare Hospice through respectful and open communication
• Willing to drive long distances under tight schedules, as required
• Must be able to cope with emotionally charged situations encompassing patients, families, and other caregivers

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Benefits:

Paid Time Off

NV Paid Leave

Medical Insurance

Dental & Vision Insurance

Voluntary Ancillary Insurance

Paid Holidays

Floating Holiday

401k with Company Match

Employee Assistance Program

Employee Discount Program

Uniforms

Welcoming Culture