The Hospice RN is responsible for providing skilled nursing care services to patients through Hospice serving a delineated geographic area under this specialized program.  This includes providing nursing care to patients in their residence on the basis of the individualized Hospice Plan of Care developed and monitored by the Hospice Interdisciplinary Team that includes the primary physician. This position requires substantial specialized knowledge, judgment, and skill based upon the principles of biological, physiological, behavioral and sociological sciences.  The RN uses critical thinking skills in making decisions regarding patient care that includes knowledge and integration of relevant standards, resources, and data.  The RN delegates the performance of selected patient care tasks to competent individuals in selected situations.  The RN delegating the task retains the responsibility and accountability for the care and coordination of care for the patient. Acting as the patient advocate, the RN has continuous contact with physician’s, patients, patient families/significant others, contracted facilities, community agencies, patient care staff, and management. 

 

PRINCIPAL ACCOUNTABILITIES 

 

• Provides skilled nursing care to patients in their residence on the basis of the individualized Hospice Plan of Care developed and monitored by the Hospice Interdisciplinary Team to include the primary physician 

• Delivers care to patients in their home efficiently and effectively, including planning sequence of visits assigned 

• Obtains and/or monitors the need to obtain physician orders to modify service intervention, including level of care, visit frequency and specific intervention/ treatment for all interdisciplinary services 

• Participates in on going patient/family unit evaluations to confirm continued Hospice appropriateness 

• Participates in the completion of the re-certification process to include the planning for all disciplines that will continue to provide care in the next certification period. The planning based on clinical documentation of the patient current status, direct contact with the primary physician and interdisciplinary team input 

• Assesses and documents bio-physiological, psychosocial, growth and developmental, environmental/safety, education, and discharge planning factors of the patient 

• Anticipates changes in patient status and includes cultural variances into assessment 

• Directly communicates to the primary physician and the interdisciplinary team patient status changes and resultant changes in the Plan of Care 

• Instruct primary caregivers, volunteers, and employed caregivers to provide care as indicated 

• Provide appropriate support at time of death and perform bereavement assessment if required 

• Develops and maintains a professional relationship with all Hospice Interdisciplinary Team members demonstrating collaborative care planning and coordination directed to achieve measurable outcomes 

• Participates in proactively planning appropriate and individualized discharge coordination including input from interdisciplinary team members, patient/caregiver and the primary physician 

• Conducts admissions as assigned based on a comprehensive in-residence assessment, patient readiness and desire for Hospice services, and patient appropriateness for Hospice services per payor source criteria and Hospice policies 

• Communicates to the office staff and/or supervisor discharge plans including projected discontinuation of services provided by all team members 

• Communicates to the office staff and/or supervisor transfer plans from Hospice to: Home Health; inpatient, outpatient, or extended care facilities; other community referrals; or other Hospice providers 

• Participates in the establishment of a Plan of Care that meets patient needs, agency policies and procedures, Medicare Hospice Conditions of Participation, Washington State Hospice licensure, and Joint Commission standards in collaboration with the interdisciplinary team, to include the primary physician 

• Ensures that care provided to patients admitted to services meets reimbursement criteria, guidelines and specifications, including Medicare, Medicaid, private insurance, and various managed care health care benefit criteria 

• Accesses and inputs documentation using automation through the electronic health record that includes programs for scheduling, billing, payroll and medical records. Maintains integrity of automated data and documentation through accurate, reliable and timely entries 

• Maintains Agency credentialing for Hospice to include emphasis on symptom management and palliative and end-of-life nursing care 

• Identifies patient care needs with reference to psychosocial, spiritual, emotional and physical aspects of the patient/family unit of care to include needed social work, volunteer, bereavement, chaplain intervention; appropriate level of Hospice Care required; secondary referral discipline referrals; medical supplies and equipment; medications; Hospice Aide and Homemaker services  

• Participates in the development, implementation and modification of the Plan of Care for all assigned patients in collaboration with the Medical Director, the primary physician, the patient and/or caregiver, and the interdisciplinary team members to meet specific patient and family needs; and to be in compliance with State and Federal regulations, reimbursement guidelines, and policy and procedures 

• Communicates appropriate patient information to office staff and/or supervisor and the interdisciplinary team to maintain an automated, proactive and comprehensive patient care schedule for all disciplines 

• Communicates canceled visits, physician appointments, physician orders changing visit and treatment assignments, and any patient communication or status that warrants consideration for changing the patient’s care schedule for any discipline 

• Participates in agency and community programs as requested to promote professional growth and understanding of Hospice and Palliative Care 

• Conducts HHA supervisory visits as required, including completion of documentation that meets State and Federal regulations and Agency policy 

• Participates in department meetings 

• Continually seeks out opportunities to promote personal continued education and professional development.   

• Completes mandatory education and training requirements 

• Fill in for after-hours RNs on a limited, as needed basis (to cover illness and vacation time) on a rotating basis 

• Adheres to MHS Attendance and Punctuality Policy and Procedure standards.  Maintains reliable attendance 

• Contributes to the success of the organization by meeting organizational competency expectations and core values, continuously learning, and by performing other duties as needed or assigned