APRN Palliative Care Home Visit Services

APRN - Palliative Care Home Visit Service

Lee County, FL

Summary

The Palliative Care Home Visit Nurse Practitioner is responsible, as part of the patient centered care team, for the overall patient care management process, with a focus on pain management, anxiety reduction, comfort measures, emotional support for patient and family, and end of life advanced care planning. An advocate for the patient, the Nurse Practitioner will provide total care for the patients assigned in collaboration with the physician of record, pain management physician, Hospice team when applicable, and all members of the patient care team. The Nurse Practitioner will communicate and manage the patients' care across all care providers, family, and caregivers. The Nurse Practitioner will ensure that timely, patient-centered, appropriate evidence-based palliative care medicine is provided. The Nurse Practitioner will assist in addressing outstanding quality measures and HCCs, as applicable, to meet or exceed all quality goals. The Nurse Practitioner will be responsible for ongoing communication with the primary care provider, palliative care nurse case manager, social worker, clergy, and other members of the patients care team, to provide for the patients physical, psychological, emotional, mental, and spiritual needs and to ensure continuity and coordination of care. The Nurse Practitioner will complete all documentation and billing in a timely manner, per protocol. The Nurse Practitioner will be responsible for other duties as assigned.

Essential Duties and Responsibilities include the following. Other duties may be assigned.

• Is responsible for the total care of all assigned patients in collaboration with the community-based physician/provider and patient care team.
• Is responsible for patient assessments and palliative care planning, initiating and assistance with advanced directives, identifying spiritual, psycho-social, and financial needs and seeking appropriate intervention, addressing quality measures and HCCs, and providing palliative comfort and end of life care, within their scope of practice.
• Provides services to meet patient needs and prevent unnecessary Emergency Department utilization when appropriate. In home services include but are not limited to: IV hydration, collaboration with Pain Management Physician for adequate pain management, lab draws, nebulizer treatments, EKGs, wound care, and injections, and utilization of mobile diagnostics as indicated.
• Ensures all pertinent and active medical conditions are documented in the electronic medical record in a timely manner, consistent with MPG policy, and in a compliant manner with CMS and other insurance carriers.
• Exhibits strong clinical skills to improve patient care for an aging, adult population; as well as excellent interpersonal relationship skills in interpreting and communicating health care information to the patient, family, and Patient Care Team.
• Provides leadership in the application of the nursing process to client care, organizational processes and/or systems improving outcomes at the program or service level and initiates interdisciplinary projects to improve organizational performance.
• Identifies patients who are appropriate and would benefit from Skilled Nursing/Therapy and initiates the SNF 3 Day Waiver for MACO qualifying patients. Follows all CMS guidelines and ensures patient is admitted to a qualifying SNF. Completes all required documentation and works with SNF Case Manager and other members of the health care team to ensure continuity and patient safety.
• Accountable for identifying patients needing additional assistance and making referrals to Home Care, Social Services, Behavioral Health, Hospice, Spiritual Care, and other available community resources, when needed and appropriate.
• Responsible for direct oversight of assigned Medical Assistant. Reports to and works collaboratively with Program Director to establish workflow processes, provisions of ongoing education/training, and employee improvement planning as needed.

Competencies:

To perform the job successfully, an individual should demonstrate the following competencies:

Analysis/Problem Assessment - Securing relevant information and identifying key issues and relationships from a base of information; relating and comparing data from different sources; identifying cause-effect relationships.

Compassion - The responsibility to put a patient's or person's interests first, including the duty not to harm, deliver proper care, and maintain confidentiality.

Compliance - Employee has satisfactory completed employers required compliance training. Employee is able to demonstrate an understandin