HH Comfort Care RN

HH Comfort Care RN

Home Health

El Paso
• Full-Time/Regular

Under the direct supervision of the HH Nursing Supervisor / HH Administrator, the HH Comfort Care Nurse, RN is responsible for the delivery of direct participant care provided to Bienvivir Comfort Care participants at their place of residence and in the clinic. The comfort care nurse provides skilled nursing care with a focus on symptom management, quality of life, and alignment with participant goals of care, while ensuring compliance with PACE, CMS and Texas Health and Human Services Commission (HHSC) regulatory requirements.

The Comfort Care Nurse is responsible for the daily coordination of participant care in the following areas: participant assessments, care planning and coordination, symptom and disease management, health education and support, prevention and maintenance, documentation and compliance, communication and team collaboration.

Direct Participant Care

• Performs skilled nursing visits in the participants' private residence, clinic, assisted living facilities, and other approved locations.
• Provides comfort-focused nursing interventions aimed at relieving pain, dyspnea, anxiety, nausea, agitation, and other distressing symptoms.
• Administers medications and treatments per provider orders, with particular attention to high-risk medications and comfort medications.
• Evaluates effectiveness of interventions and modifies care delivery in collaboration with the interdisciplinary team (IDT).

Nursing Assessments

• Complete initial, ongoing and as needed required nursing assessments of individual participants, including evaluation of medication compliance, change of condition, symptom burden and functional status.
• Routine visits will be completed on the participants scheduled Interval Assessment date, in accordance with the CMS guidelines.
• Initial start- of- care in-home assessments will be completed within 72 hours of the participants' enrollment into the comfort care program. Consequently, monthly assessments will be completed in compliance with Texas Health and Human Services Commission (HHSC) requirements.
• Complete reassessments promptly upon the request of participant/ or designated representative, with urgency determined by the severity of the participant's condition.

Care planning and Coordination

• Develops, implements, and updates individualized comfort care plans in collaboration with the participants, caregivers, providers, and IDT.
• Ensures care plans are consistent with participant goals of care, advanced directives, that meet the standards mandated by PACE, HHSC and nursing practice.
• Coordinates daily care needs across disciplines, including providers, pharmacy, social services, rehabilitation, and any other discipline, as appropriate.
• Facilitates transitions of care and supports continuity across settings.

Symptom Management and Disease Management

• Implements evidence-based comfort care interventions for participants with advanced illness and chronic disease.
• Monitors disease progression and symptom trends through ongoing assessment, including weekly telephone follow-ups with the participant and/or caregiver, to proactively adjust care strategies as needed.
• Supports the management of chronic conditions within a comfort-focused plan of care, prioritizing symptom relief while minimizing unnecessary or burdensome interventions.
• Observes participants for changes in condition and promptly reports findings to the Comfort Care provider and designated clinical leadership.
• Collaborates closely with providers to recommend medication adjustments, alternative therapies, and supportive measures based on participant response and goals of care.
• Obtains and implements provider orders for changes to the medical plan of treatment in response to changes in the participant's condition.
• Works collaboratively with providers in the daily management of participant care, including monitoring ill participants, assisting with procedures as indicated, and ensuring timely implementation of prescribed medications and treatments.
• All assessments, observations, interventions, communications, and participant responses are documented accurately and timely in the medical record.

Health Education and Support

• Provides ongoing education to participants and their caregivers regarding disease processes and anticipated progression.
• Educates on the purpose of medications—including end-of-life and comfort-focused medications—the proper administration of these medications, and potential side effects.
• Instructs participants and caregivers on symptom monitoring, comfort measures, and safety practices to support effective self-management and promote participant well-being.
• Reinforces education of the Comfort Care Program in a culturally sensitive and participant-centered manner.
• Supports participants and caregivers emotionally, addressing concerns related to comfort, coping, and care expectations.

Prevention and Maintenance

• Implement strategies to prevent hospitalizations and Emergency Room visits.
• Prevents…