Hospice RN - Racine

Job Overview

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Location:
Racine County

1.0 FTE (40 hours/week) | Day Shift | Monday-Friday | 8:00am-5:00pm

Includes weekend (every 3rd /4th), and holiday (2/year) rotations

The RN – New Market provides patient and family centered care in new geographic markets; they establish, provide, and ensure care consistent with Agrace philosophy, goals, standards, regulations, and policies. This role is responsible for evaluating potential patients for hospice and palliative care, admitting patients to Agrace’s homecare program in new markets, and ensuring patient and family satisfaction through the provision of nursing care and case management by conducting assessments, triaging patient needs, creating and updating the plan of care, providing interventions, communicating, and documenting.

Due to the nature of work in new geographic markets, percentages of time listed for each essential function may vary based on needs.

• Patient and Family Assessments and Evaluations
  • Review medical records to identify hospice and palliative care services eligibility, physician orders, and to verify diagnosis.
  • Identify if patient meets admission criteria in collaboration with primary care, specialty, and Agrace physicians. Collaborate with IDT and primary care provider to create HES for determination of hospice eligibility.
  • Identify if patient meets admission criteria by assessing patient’s physical, pain, psychosocial, emotional, spiritual, environmental, fall, medication safety, and educational needs. Collect data from the patient, family, significant other and other health care professionals about immediate goals and needs.
  • Collect data from the patient, family, significant other, other members of the interdisciplinary team, and other health care professionals about immediate and longer-term goals and needs.
  • Serve as a consultant to patients and families about end-of-life issues and Agrace programs philosophies and services.
  • Identify, interpret, and document assessment data collected in the nursing interview, physical assessment, and other health data.
  • Serve as a resource and consultant for hospital/clinic staff, physicians, nurses, social workers, chaplains about pain, symptom management, end-of-life issues, hospice/palliative care philosophies and services.
  • Document and report significant changes in condition or unusual incidents to appropriate IDT member such as client abuse/neglect, suicidal intent, harmful coping mechanisms or violence, etc.
  • Collaborate with manager regarding all patients deemed ineligible for hospice services.
  • Actively pursue relationships and develop partnerships with all referral sources to promote the benefits of Agrace services.
• Patient Care
  • Assess patients and family’s physical, pain, psychosocial, emotional, spiritual, environmental, and educational needs as outlined by the plan of care (POC).
  • Respond to patient and family needs or change in condition or need for acute patient intervention.
  • Provide interventions, treatments, and pain management to patient and family to meet needs. Evaluate the effectiveness of pain management or other intervention and adjust to meet needs.
  • Provide patient and family education on pain, symptom management, end of life, etc. Evaluate the effectiveness of education and adjust to meet needs.
• Plan of Care
  • Formulate, implement, and revise individualized POC in collaboration with Interdisciplinary Team (IDT), patient, and family. POC to include goals, pain management, interventions, education, discharge plan, etc.
  • Develop reasonable and achievable outcome measures and establish priorities in the planning and provision of care.
  • Obtain medication and other orders.
  • Order durable medical equipment.
  • Read, understand, and follow the plan of care. Document interventions, outcomes, and changes in patient condition in electronic health record (EHR).
  • Delegate visits to appropriate disciplines and manage visit sets.
  • Oversee work of Certified Nursing Assistants (CNA) and Licensed Practical Nurses (LPN).
• Miscellaneous
  • Participate in meetings to plan and evaluate…