The Home Hospice Registered Nurse plans, organizes and directs home hospice care services, initiates, and implements care primarily in the patient’s home environment. The Home Hospice RN fulfills the role of skilled communicator, educator, leader and motivator. The Hospice RN ensures that high standards of patient care are met at all times.
- Ensures compassionate, empathetic quality and safe delivery of services to patients according to care plan. Uses equipment and supplies safely, effectively, and efficiently.
- Consistently utilizes a patient-centered approach considering physical, psych/social, spiritual, educational, safety and related criteria appropriate to the age of the patients served in hospice.
- Integrates and coordinates the care of the at-risk population across the healthcare continuum making assessments, planning interventions working closely with providers and overall patient care team.
- Facilitates the interdisciplinary plan of care to meet multiple service needs as well as promote continuity through elimination of fragmentation of care/service
- Delivers quality care consistent with Hospice Conditions of Participation, qualifying hospice criteria, payer coverage criteria, and providing visits/treatments consistent with the plan of care to honor patient/ family values/ wishes
- Conducts clinical review of record to include multi-disciplinary review, coordination of care, provided in conjunction with visits and documentation.
- Identifies risk for acute hospitalization and proactively prevents adverse events.
- Responsible for looking at the individual needs of each hospice order/referral and determining eligibility for hospice services and appropriate level of care.
- Assist with implementation and coordination of services required for discharge of patients from hospitals into Hospice’s program of care
- Responsible for coordinating the patient care team in providing quality, cost effective patient care in the hospice environment
- Promotes the provision of comfort care to the dying as an active, desirable, and integral component of nursing care in the home.
- Uses scientifically based standardized tools to assess symptoms (eg., pain, dyspnea, constipation, anxiety, nausea/vomiting, and altered cognition) that are expected by patients at the end of life.
- Collaborates effectively with patients, families, and other members of the Interdisciplinary Team to develop an individualized plan of care to attain specific goals and outcomes.
- Utilizes effective teaching and learning strategies when providing hospice education for patients, families, colleagues, and community.
- Coordinates regular scheduled intermittent visits to patient’s home environment, coordinates level of care changes when appropriate to pain/ symptom management, assesses and implements increased frequency of visits when patient condition warrants
- Participates in on call schedule to provide 24 hour coverage- makes emergency unscheduled visits during on call hours
Achieve certification in Integrated Care Management within 1 year of hire. Certification includes completing the Integrated Care Management formal training session, successfully completing assigned computer based-learning modules within 2 weeks of training, and a competency evaluation. Use the Integrated Care Management philosophy, skills, tools and documentation in clinical practice. Demonstrate competency in selected ICM skills annually