The Hospice Transitions RN, as a member of the Advanced Care Management department, identifies, assesses, and prepares hospitalized patients and their loved ones for the transition to end-of- care. Coordinates the discharge plan, problem solves, and documents actions and plans while collaborating, consulting, and advocating on the patient’s behalf. Holding continuity of care as a priority, communicates and coordinates with the larger healthcare team including the hospitalist, nurse, patient care facilitator, social worker, and palliative care.  Receives and follows up on hospice referrals by meeting with the patient/family, introducing hospice services, evaluating the patient’s status, eliciting choice for post-acute providers, facilitating orders, and anticipating needs for equipment, medication, and transportation

Education:

• Graduate of an accredited College of Nursing, with a Bachelor’s degree required.

Licensure/Certification/Registry:

• IL Licensed Registered Nurse required.
• CPR Certification required.

Experience:

• Minimum three (3) years in nursing experience required.
• One (1) year experience in hospice or palliative care required.
• Experience in acute-care hospital setting; knowledge of discharge planning/case management preferred..

Other Knowledge/Skills/Abilities:

• Must have clinical knowledge and critical thinking ability to create a viable and effective patient transition plan an identify barriers in service, effectively conduct verbal and written patient assessments, carry out the referral processes, and coordinate with other individuals involved in the plan of care.
• Understanding of home hospice services and regulations.
• Knowledgeable about disease states and prognosis and how illness progresses clinically and functionally.
• Self-starter with a high degree of initiative
• Ability to work as part of a team as well as form harmonious working relationships with post-acute providers
• Excellent collaborative and problem solving skills
• Excellent organizational skills
• Excellent interpersonal and communication skills
• Strong commitment to teamwork and patient experience

1. Identifies, assesses, and prepares patients (and their families) for transition to home hospice care

• Reviews hospital plan of care and current discharge planning efforts
• Gathers additional information from the patient/family interviews, medical record, physicians, and other healthcare providers
• Understands current and future disease states and can accurately match patient’s needs to appropriate level of service
• Formulates a transition plan after reviewing available/appropriate care options and obtaining input from the patient/family, and the physician, healthcare team, and post-acute care providers
• Identifies patient’s person-centered goals-of-care and provides education to the patient and family about home hospice’s line of services that would help meet those goals
• If needed, for hospice patients receiving General Inpatient Level of Care, assist with admissions and daily visits when directed, coordinate with the hospice Interdisciplinary team
• Maintain accurate daily documentation including patient assessments, plans, interventions, patient/family involvement, coordination with physicians, colleagues, and post-acute care providers

2. Coordinates care, problem solves, and documents actions and plans
   • Utilizes professional judgment to determine the need for a family meeting, escalation to leader, and other problem solving measures
   • Monitors transition plan and intervenes in an appropriate and timely manner with difficulties arise
   • Identifies, communicates, and creatively develops efficient delivery of care as the patient moves to home hospice services
   • Enters referral information and documents interactions in the appropriate electronic medical record

3. Collaborates, consults, and advocates
   • Develops and maintains positive, productive relationships with colleagues
   • Provides educational opportunities in hospital, collaborating with peers and palliative care team as appropriate
   • Actively participates in rounds with other team members to effectively coordinate and facilitate transition plan

4. Adheres to departmental and organizational protocols, policies and procedures, and supports operational and strategic plans and objectives
   • Demonstrates competencies related to service line knowledge, edibility criteria, regulations, and processes
   • Adapts to changes in the work environment or work process in a timely, positive, and effective manner
   • Demonstrates a commitment to teamwork by willingly accepting responsibilities and performing assignments that support the team
   • Completes all annual competency validation requirements
   • Actively participates in department meetings and operations
   • Identifies new systems or processes, protocol, and/or methods to improve practices
   • Maintains confidentiality of patient information
   • Demonstrates knowledge of appropriate utilization of internal and externa resources to meet patients’ needs
   • Ensures quality standards are met. Follows all applicable licensure regulations and commonly accepted professional standards of practice
   • Utilizes time well to ensure follow-up is completed and needs of patient/family or healthcare providers are anticipated and proper plans are executed.

5. Performs other related work as required or requested.

 The intent of this job description is to provide a representative summary of the major duties and responsibilities performed by incumbents of this job.  Incumbents may be requested to perform tasks other than those specifically presented in this description.