Oversees, coordinates, facilitates and supports the interdisciplinary teams that provide care to patient/families of VNSNY Hospice Program. Responds to triaged incoming calls from patients/families/caregivers requiring clinical management and oversight, which includes assessing needs and making appropriate determination of required actions within context of patient's Interdisciplinary Plan of Care and Hospice Care mission, objectives, policies and procedures. Ensures the care directed to acute symptom management is provided within the standards of practice for all clinical disciplines. Documents and reports to team patient's needs, significant events, plan of care and other issues. Evaluates effectiveness of clinical directions. Demonstrates knowledge and commitment to excellence in clinical practice and customer service. Works under general direction.
- Ensures the interdisciplinary care provided to patient/families of VNSNY Hospice Program and contractual partners is directed to meet the comprehensive medical, physical, social, emotional and spiritual needs of the patient and family.
- Performs telephonic skilled nursing assessment of the physical, emotional and medical needs of Hospice patients and their caregivers. Provides support and direction to families in accordance with the patients' Interdisciplinary Plan of Care and Hospice care missions, objectives, policies and procedures. Determines need for visit and assigns nurse, social worker and/or spiritual care counselor as appropriate; provides necessary information and follows up regarding status of visit.
- Takes referral information and triages for immediate response. Notifies intake department in a timely manner.
- Provides clinical direction to patients/caregivers in accordance with Hospice guidelines, Obtains and receives verbal orders from team/physician and documents care using standard form. Evaluates and documents effectiveness of directions through telephone follow up with patients/caregivers, Provides team/physician with documentation and implements any changes, as appropriate.
- Follows up with Hospice Team Managers to ensure individual patient situations are met, including advising HTM of staffing assignments. Contacts field staff, MD's, clients, family members, other care givers and/or vendors to direct care management to ensure that patient needs are met.
- Consults and collaborates with field operations management staff to resolve complex clinical issues.
- Obtains and reviews daily report from each team on significant patient care situations that may require contact/follow up. Documents all calls received using high degree of accuracy and attention to detail to ensure team/physician is provided with all relevant and necessary information.
- Participates in Interdisciplinary Hospice Team Meetings, patient visits and performs clinical supervision of staff when needed.
- Assists administration to ensure full regulatory compliance with Hospice Conditions of Participation, standards of practice, compliance with VNSNY Hospice policies and procedures and contractual services.
- Collaborates with Quality Improvement/Education in the development and implementation of quality improvement and educational activities to ensure professional practice standards are consistently met for each member of the interdisciplinary team. Works effectively with administration to design, implement, evaluate and modify quality initiatives and educational plan as directed and appropriate.
- Communicates effectively with VNSNY Hospice Care management and hospice agencies under contractual relationship with VNSNY Hospice Care.
- Serves as an effective member of the clinical team demonstrating teamwork, effective supervision and collaboration at all times.
- Provides guidance and support to Customer Service Representatives (CSR) to encourage team learning around implementation/evaluation of plans that maintain/increase customer response and quality care compliance with regulatory standards.
- Provides input to Hospice Team Manager regarding staff performance for annual performance evaluations
- Participates in special projects and performs other duties as assigned.
License and current registration to practice as a Registered Professional Nurse in the state of New York required. Valid driver's license or NYS Non-Driver photo ID card, may be required as determined by operational/regional needs.
Bachelor's degree in Nursing or equivalent work experience required.
Minimum of three years of experience in nursing required. Experience is Hospice or Palliative Care preferred. Excellent oral, written and interpersonal skills required. Attention to detail, excellent follow up and follow through skills required. CA2020
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