Care Navigator-RN-Bryan Palliative Care

Summary

GENERAL SUMMARY:

Supports and promotes the continuum of care for their patient population. Provides individualized assistance to patients, families and caregivers to promote optimal outcomes. Works collaboratively with physicians, staff and other providers across the care continuum.

Plays a key role in supporting the clinical care for patients referred for palliative care consultation. Includes working with the interdisciplinary palliative care consult team of physicians, advanced practice nurses, medical learners, chaplains and social workers to deliver excellent patient and family care. Supports the team in achieving clinical standards across the continuum of hospital, clinic and community settings, coordinates resources and provides palliative nursing care.

PRINCIPAL JOB FUNCTIONS:

1. *Commits to the mission, vision, beliefs and consistently demonstrates our core values.

2. *Facilitates the coordination of patient care services to ensure timeliness and excellence in patient care including coordination of services, treatment and communication among the medical team.

3. *Facilitates development, implementation and adherence to clinical and evidence-based guidelines, as appropriate, to ensure optimal clinical outcomes.

4. *Identifies and addresses barriers to timely and appropriate diagnosis and treatment, connects patients with the appropriate healthcare and community resources.

5. *Builds therapeutic and trusting relationships with patients, families and caregivers through effective communication and listening skills.

6. *Provides anticipatory guidance, education and psychosocial support throughout the care continuum.

7. *Maintains patient records accurately, completely, timely and confidentially according to procedures. Documents patient encounters and provided services.

8. *Supports the continuity of care for optimal patient outcomes; performs telephone follow-up calls on patients post hospitalization and at regular intervals as appropriate.

9. Assists in the identification and reporting of quality issues and contributes to the performance improvement plan to assess and improve the quality and efficiency of the program including, but not limited to quality assessment, recommendations for program improvement and patient outcomes measures.

10. *Exhibits behaviors and actions which create a high level of patient/customer satisfaction, which contributes to positive patient/customer relations and which reflect respect for the patient's/customer's rights, needs and confidentiality.

11. Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise.

12. Participates in meetings, committees and department projects as assigned.

13. Performs other related projects and duties as assigned.

ADDITIONAL JOB FUNCTIONS:

1. Coordinates patient and provider flow

* Participates in developing structures and functions to support the palliative care team’s assignments and volumes

* Prepares morning census accounting for patient changes and daily staffing

* Attends MDR and contributes to patient discussions as appropriate

* Creatively manages resources and staffing to triage consults and manage day to day clinical needs by facilitating communication with palliative care team members and referring providers or ancillary services

* Implements triage parameters to meet immediate needs and facilitates an interdisciplinary approach to palliative care

* Assists team members in coordinating services provided by palliative care and other health care team members

* Provides clinical care within the RN scope of practice, documents assessments and reports moderate to distressing symptoms to palliative physicians/APPs

* Participates in advance care planning discussions with patients and families and completes documentation (advance directives)

* Communicates updated plans of care to referring providers and unit clinical teams and ensures follow through

2. Functions as a resource to patient care units and patient care staff regarding palliative care

• Identifies learning needs of patient care staff and communicates these to nursing and program leadership

• Provides education to patients and their families about palliative care, advance care planning, services available

• Provides education to hospital staff as requested

• Identifies and communicates opportunities for quality improvement to program leadership

• Sees the big picture and uses systems thinking to understand the unintended consequences of decisions.

• Sets appropriate priorities among competing demands.

• Uses available information technology to support day-to-day work operations.

3. Focuses on the patient/family experience

• Understands & sets and example of exemplary customer service.

• Continuously builds customer understanding by listening to customers.

• Anticipates customer needs, including those with different cultural needs and desires.

• Takes action to meet and exceed the needs of all customer groups.

• Continuously implements strategies to improve customer satisfaction.

EDUCATION AND EXPERIENCE:

Current Registered Nurse licensure from the State of Nebraska or approved compact state of residence as defined by the Nebraska Nurse Practice Act required. BSN preferred. Minimal of three (3) years recent clinical experience required and ambulatory clinic experience preferred.

OTHER CREDENTIALS / CERTIFICATIONS:

Basic Life Support (CPR) certification required. Bryan Health recognizes American Heart Association (for healthcare professionals), American Red Cross (for healthcare professionals) and the Military Training Network.

ADDITIONAL REQUIRED CREDENTIALS / CERTIFICATIONS:

Hospice or Palliative care experience strongly preferred.

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