Nurse Practitioner GGL Community-Based Palliative Medicine

Overview

Under general supervision, accountable for the palliative clinical management (to include, but not limited to symptom management, advance care planning, and counseling and supportive services), as well as the care coordination of those patients living with serious illness who are becoming increasingly limited in their ability to perform personal activities of daily living, independently, in the community-based setting. The community-based setting includes patients' homes, private residences, senior living communities and skilled nursing facilities.

Successful completion of a Certified Nurse Practitioner program

• At least five (5) years of related experience in a healthcare environment.
• At least one (1) year of Geriatric or Palliative NP experience at patients  home, within skilled rehab, long term care or assisted living settings
• At least one (1) year of Home Care or Hospice/Palliative Care.

• Skill in using computer, familiarity with the use of electronic medical records
• Effective written and oral communication skills to communicate and relate effectively with patients, family, staff, other home-based providers, the public, physicians, referring and partner health systems and practices and insurers.
• Skill in effectively collaborating with a wide variety of service providers who also are working with the patient and with the CBPC team members.
• Skill in effectively working with patient/family with challenging psycho-social, and socio-economic issues and circumstances.
• Analytical skills in order to assess patients and implement appropriate intervention, care plans, and treatments
• Able to work under varying degrees of stress and the ability to adjust to changes in the work environment.

• Current registration with the Maryland State Board of Examiners of Nurses as a Nurse Practitioner, specializing in Adult, Family or Geriatrics
• Current CPR certification
• Hospice and Palliative Care Certified is preferred

• Assumes Consultant responsibility for the initial evaluation and treatment of patients in assigned areas.
• Performs initial history and physical as evidenced by appropriate documentation, including medication reconciliation
• Reviews, Instructs and Completes Advanced Care Planning with patient and/or families with initial meeting and subsequent visits, as needed and indicated.
• Writes appropriate orders related to newly diagnosed and pre-existing conditions, in coordination with the primary care provider and/or specialists involved with care.
• If acting in a consultative role, discusses with the referring and/or attending physician, as appropriate, physical and/or emotional findings, which may interfere with care of the patient.
• Ensures review, consent for, and enrollment in the chronic care management program as appropriate.
• Communicates findings with HBPC team and coordinates plan of care

Evaluates patient progress on a continuing basis and in collaboration with the referring physician, as appropriate and alters treatment modalities as needed.

• Evaluates nursing, medical, social and educational needs on assigned patients.
• Initiates referral to appropriate community resources based on patient need and documents on the progress note.
• Writes/Types progress notes for each visit documenting pertinent information regarding patient progress and treatment regime.
• Writes orders appropriate to the patient s care requirements in compliance with existing contract.
• Establishes medical diagnoses in compliance with contract.
• Refers to the physician or designee, as appropriate those problems which require consultation and documents same on progress note.
• Makes immediate referral of acute and or life threatening patient conditions to emergency department or hospice as appropriate per patient care plan. Documents physical findings and treatment plan pertaining to same.
• Uses electronic health record system to document all activities with the patient and family.

- Performs technical functions as covered by the job description, in accordance with GBMC policy.

• Documents results of technical functions performed.
• Reports to physician or designee, as appropriate any abnormal findings related to it when appropriate and if indicated.
• Monitors patient response related to technical function performed and documents it.
• Acts as a clinical resource.
• Actively supports and participates in departmental performance improvement initiatives.
• Actively participates in Gilchrist/Palliative Medicine meetings and conference calls and in group functions, including an equitable share of on-call responsibilities, attendance at meetings and periodic planning activities

- Performs activities to meet patient/family educational needs.

• Participates actively in health teaching of patient and family to include preventative health care as well as current medical condition and treatment regime. Evidence of same by documentation on progress note and/or established flow sheet.
• Review discharge…