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Jordan Hospital RN- Hospice Case Manager in Plymouth, Massachusetts

Essential Functions

· Provides care according to and is able to articulate hospice philosophy

· Function as a member of an interdisciplinary team that includes the patient and family in the development of a patient specific plan of care driven by the patient's goals and preferences.

· Functions as the "eyes and ears" of the physician in the home or facility, communicates an accurate assessment of the patient's condition to the physician and offers expert guidance on treating end-of-life pain and other symptoms when requested by the physician

· Performs RN pronouncement in all settings except the acute care hospital

· Provides an initial assessment in conjunction with established LCD guidelines to ensure patient meets criteria for admission to hospice.

· Provides assessment and clear documentation in the EMR (PTCT) to demonstrate patient continues to meet hospice eligibility utilizing appropriate scales (i.e. FAST, ECOG, etc.)

· When services of the hospice chaplain and/or social worker are declined by the patient/family, obtain data on psychological, social and spiritual factors that may influence the patient's plan of care. Seeks input from other members of the team to increase knowledge and support.

· Provides skilled service that ensures the nursing needs of the patient are met as identified in the patient's initial assessment, comprehensive assessment and updated assessments

· Prepares and submits updates to patient care plan for review by the Interdisciplinary Group at least every 14 days and prior to each recertification period.

· Assumes primary responsibility for the coordination and management of all aspects of the patient's plan of care.

· Initiates and maintains consistent communication with the attending physician, the Hospice Medical Director, the hospice pharmacist(s), other members of the IDG , hospice office staff, clinical supervisors and directors, other agencies and facilities as needed to coordinate optimal care and use of resources for the terminally ill patient and family

· Considers factors related to safety, effectiveness and cost in planning and delivering patient and family care

· Proactively informs Clinical Supervisor or Clinical Director of unusual or potential problems.

· Works with pharmacist and primary care physician to utilize medications that are optimal and yet cost-effective.

· Follows process to arrange for the delivery of medications as ordered, understanding the variation in the process for each care location (ALF, SNF, group home or private home)

· Educates patient, family and contracted caregivers on medications and other care processes to maximize patient comfort.

· Documents patient care issues, goals and plans in the electronic medical record and exports data to be shared with other clinicians in a timely manner.

· Documents in the electronic medical record per agency standards to ensure accurate retrieval of quality indicators.

· Meets routinely with staff in assisted living, skilled nursing facilities and/or group homes to coordinate the plan of care

· Provides excellent Customer Service to patients, families and facilities, by being knowledgeable and respectful of the patient's "home" environment and regulatory requirements and preferences of each setting.

· Supervise the care provided by Hospice Aides at least every two weeks with an annual face to face supervision

· Provide appropriate support at time of death and offers bereavement support

· Maintains competency in all end-of-life issues, pain and symptom management

· Participates in agency programs and community education as required to promote growth and understanding of hospice care

· Demonstrate knowledge of agency policies, State Regulations, the Medicare Conditions of Participation, Joint Commission requirements, Long Term Care Facility regulations, and Assisted Living regulations. Algorithms for end-of-life symptom management.

· Participate in in-service training and education with a goal of achieving RN certification in Hospice and Palliative Care

· Participate in Quality and Performance Improvement Activities

· Other duties as assigned by Clinical Director


Current Massachusetts professional RN license

Baccalaureate degree in nursing from an NLN accredited program preferred

Hospice & Palliative Care or Holistic Nursing certification preferred

Recent Hospice Case Management or Hospice RN Supervisory expereince required

Expertise in EMR (PTCT) required hospice documentation

Demonstrated ability to manage all aspects of terminal care with expertise in pain and symptom management, IV and SC infusion, knowledge of compounded medications

Demonstrated ability to assess and respond to needs of patients and families in a variety of settings required

Demonstrated customer service is essential

Valid Massachusetts driver's license and access to reliable transportation