RN Clinical Liaison

Company:

Providence at Home with Compassus

 

This position represents Compassus Providence JV (JV) Agencies at contracted Providence facilities and requires strong communication and interpersonal skills. The role of the Clinical Liaison RN is to coordinate and arrange home care services between Providence hospital facilities and the JV Agencies for home health and hospice, and other community providers when specifically requested by the patients.

The position acts as a clinical resource and educates hospital staff regarding the services offered by JV, and enhances the patient care plan as it relates to the discharge plan. The Clinical Liaison RN provides information to ensure a smooth transition for patients and their families following hospitalization. The Clinical Liaison RN position is salaried and will not receive any bonus or compensation related to assisting with admissions to the JV home health agencies or hospices. The Clinical Liaison RN may be assessed for success of achieving Value-Based Enterprise measures.

Position Specific Responsibilities
• Assesses referrals for appropriateness for home care and hospice to include medical, physical, social, and emotional status, home environment and family's acceptance and ability to care for the patient in the home and determine the need for equipment.

• Coordinates discharge planning for hospital inpatients to home health and hospice service needs of referral sources including physicians and authorized mid-level practitioners (e.g., ARNP or PA) including but not limited to those who are hospital-based, work in clinics, physician offices or elsewhere in the community.

• Provides home care information/education at meetings with hospital service, utilization review/discharge planners/case managers, patients and patient's families and educates hospital medical and physician/mid-level staff, patients, and patient's families to available home care services.

• Acts as liaison between patients, families, payors, physicians, Providence discharge planners, and the network providing complete physicians' orders, referral information to the network intake department .

• Assumes initial responsibility with Hospital discharge planning team for assessing patient/family needs for Home Health, Hospice and consults with the attending physician, Hospice Medical Director, intake team and other staff members as necessary.

• Plans for admission of patients to Home Health, Hospice in coordination with agency representative, patient/family, Hospitalist and primary physicians/attendings, Medical Directors and hospital case manager/discharge planner.

• Contributes to the clinical determination of a patient's appropriateness for Home Health and Hospice services consistent with applicable policies and admission criteria and in conjunction with patient's physician or appropriate mid-level practitioner.

• Facilitates transition of patient/family to primary nurse and other members of the hospice Interdisciplinary Group (IDG) as indicated for patients who elect hospice after determined to be hospice eligible.

• Coordinate the expansion and implementation of the GIP (General Inpatient Care) Hospice Program in conjunction with hospice team.

• Attends appropriate meetings to promote Home Health and Hospice referrals and GIP as appropriate.

• Maintains and builds existing relationships with post-acute care providers by serving as a resource for education and information.

• Evaluates referrals received on hospitalized patient from a variety of care settings for appropriateness for Home Health and/or Hospice [or other in-home services programs as appropriate ].

• Coordinates with the Inpatient Hospital Team and primary RN/MSW to ensure discharge planning is comprehensive and communicated efficiently.

• Appropriately documents activities in the Providence and JV’s electronic medical system; tracks referrals received by nursing unit and accepted by each JV agency.

• Actively participates in development and execution of strategic initiatives that include increased Value Based Enterprise care coordination and discharge planning services for applicable post-acute care patients who will receive home health or hospice care following the hospital inpatient discharge.

• Attends scheduled meetings and engages in appropriate oversight communications with the Clinical Excellence Team.

• Assists patients/representatives complete and obtain Hospice Election Statements and hospice consents.

• Assists patient/representatives complete and obtain home health agency consents.

• Assists physicians/mid-level practitioner with the admission of patients onto Hospice services as appropriate, though only physicians may certify a patient i