Geriatric & Palliative Care Case Manager Nurse

Description

The Palliative Care Nurse serves as the nurse case manager for a geriatric and palliative care population providing primary and chronic care management, primarily coordinating care with the patient and patient caregivers from enrollment through discharge of services. This care delivery may take place via telephone, in-home/facility visits and/or telehealth services. The Palliative Care Nurse utilizes the nursing process and Alive’s visit standards to provide safe, supportive and effective care management.

Care provided should be within nursing scope of practice and aligned with the patient’s goals, throughout the disease process, including symptom management, education, and psychosocial support which may include appropriately utilizing resources of social work or chaplaincy as needed. Due to the variety of variables that may impact navigation of care for this population, flexibility, organization, and building rapport rapidly with patients and their caregivers is highly valued.

The Palliative Care Nurse will be accountable for meeting Alive Care Standards and collaborating effectively with Alive team members as appropriate.

• Present a Professional Image
  Represents Alive in a positive manner. Takes pride in personal appearance, conforms to Alive standards of dress code, car cleanliness, driving etiquette and appropriately prepared for visits. Presents self to the public in a calm, confident, competent manner.
• Provide Excellent Customer Service
  Conducts visit in a professional, courteous manner, projecting warmth during interactions with patient & family. Engages in purposeful conversation using appropriate body language and active listening skills.
• Assess, Plan, Intervene and Educate
  Utilizes critical thinking skills and nursing process to holistically assess patient and family, develop and implement a plan of care that aligns with patient’s goals, including utilization of IDT resources. Educate family/caregiver(s) regarding plan of care, interventions, diagnosis and prognosis, medications, use, administration and side effects, how to provide care, use of equipment and supplies and how to contact Alive for assistance.
• Document at the point of care
  Completes documentation of patient visit same day and documenting accurate reflection of patient’s care; updates plan of care same day or more timely if indicated.
• Create a lasting impression
  Concludes patient visit by providing encouragement to patient and caregiver(s), ensuring use of emergency phone number (Call Center Number) and anticipatory needs prior to next visit have been met. Engages in active listening and expresses gratitude before leaving home.
• Complete post visit follow-up
  Concludes entire encounter according to Alive CARE visit standard: follow up messages to team members as needed, synchronize iPad, and spiritual release of the visit.

• Demonstrates effective communication skills and acts a liaison between Alive and the patient’s primary geriatric - palliative provider or other medical providers involved in the patient’s care.
• Communicates and collaborates with providers, medical directors, outside facilities and other health care providers regarding patient assessment and response to plan of care.
• Notifies appropriate staff of status changes per Alive procedure and collaborates with team members to assure appropriate, empathetic and effective patient/care giver support and care.
• Reports unusual and problematic patient/care giver issues to appropriate supervisor, and other IDT members as…