Palliative Care RN, North of Boston

Position Summary

Commonwealth Care Alliance's (CCA) Palliative Care Team, comprised of multi-disciplinary clinicians, will provide care consultation and delivery on an on-demand basis in addition to providing scheduled non-urgent services to dually eligible CCA members, a group of individuals with significant medical, behavioral, and social complexities that require intensive support.

The Palliative teams are comprised of nursing (RN), advance practice (NP) and Behavioral Health (LICSW) team members.

The Palliative RN reports to the Palliative Manager and is called upon to work within the interdisciplinary team to comprehensively evaluate and formulate a palliative management plan for patients needing goals of care conversation, experiencing an acute event or significant change in condition and/or end of life management and planning. The Palliative RN provides episodic advanced serious disease management, urgent visits, promotes preventative care and wellness, pain management, and augments the provision of end of life/palliative care.

The role also includes providing input to other palliative team members, outside providers and patient s' care teams on key care management/care coordination decisions, including the adjustment of the patient-centered care plan and identification of the need for durable medical equipment and services, consideration for re-stratification and planning for end-of-life location.

No, this position does not have direct reports.

• Performs episodic urgent and scheduled medical visits for palliative s to ensure that theyare given timely and appropriate medical care regarding symptom management and education about disease trajectory as well as options available in order to avoid unnecessary emergency room visits or hospitalization. Visit includes a detailed history of present illness, review of systems, medication reconciliation, physical exam, recommendations in consultation with NP/PA or physician before reaching out to outside providers.
  
  Reviews appropriate studies and tests, develops a plan of care, and shows evidence of follow-up through timely documentation according to policy at CCA.
• Facilitates and/or delivers palliative care to patients according to the guidelines deemed appropriate by CCA Palliative Leadership. Guidelines may vary based on the patient's goals of care, as CCA offers concurrent care for patients with serious illness.
• Identifies and initiates a plan to resolve areas of opportunity to meet quality and operational metrics.
• Provides regularly scheduled follow-up visits for patients facing end of life and palliative care. Visits are inclusive of a history of present illness, review of systems, physical exam, medication reconciliation, recommendations in consultation with supervising NP or MD for ordering of appropriate studies or tests, adjustment or maintenance of an established treatment plan, and consistent follow up of the plan as evidenced in the documentation.
• Documents all activities and results using an Electronic Medical Record, in an effective manner while strictly adhering to CCA policies and procedures.
• Adjusts the patient-centered plan of care as necessary based on a significant change in condition. A change in condition is an event (hospitalization, acute illness, etc.) which results in either a short- or long-term change in need.
• Utilizing and depending on CCA internal resources, ensures that the plan of care is implemented in a timely manner.
• Provides end of life care to a panel (in coordination with Care Partners) in a manner that is consistent with helping the patient and caregiver identify goals of care, anticipate changes needed as patient’s condition declines along the disease trajectory.
• Helps patient and caregiver navigate end of life decisions related to goals, incorporating realism and safety in a way that also empowers them to make the decisions that are best for them.
• Shows an ongoing commitment to learning about the tenants of Palliative Care through ongoing pursuit of education and obtaining certification if not already certified in hospice and palliative care.
• Provides clinical care to patients via telehealth technologies (video, chat, etc.) for a clinically appropriate clinical care and care management services.
• Outreach to existing clinical partners promoting and educating about Palliative Care.
• Participates in cross-organizational working groups to continuously improve team performance as requested.
• Identifies and suggests improvements to clinical programs, initiatives, processes, policies, workflows, and projects.
• Participates in CCA Quality Improvement efforts.
• Participates in committees and work groups that promote clinical excellence and help to advance CCA's mission and business objectives as requested.
• Provides coaching and mentorship to new employees as requested by CCA Palliative Leadership.
• Other projects and requests made by Palliative Manager.

• Must be willing and able to…