Supportive Care, RN

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We're changing lives every day. For both our patients and our team members. Are you innovative and entrepreneurial minded? Is your work ethic and ambition off the charts? Do you inspire others with your kindness and joy?

We're different than most primary care providers. We're rapidly expanding and we need great people to join our team.

The Supportive Care, RN is the clinical and operational care of patient engagement for the serious illness management panel in the market who need active palliative care involvement. Working alongside palliative care and specialty care team members, this position builds trust with patients facing serious, advanced illness; conducts comprehensive assessments in the home, center, or other facilities; monitors proactively for early signs of clinical deterioration;

validates findings with the patient's PCP; coordinates care across specialists and care settings; and escalates to the Physician/NP when a case exceeds nurse-level management.

This role is essential to identifying decline early, managing symptoms at home, preventing unnecessary emergency department visits and hospitalizations, and helping patients and families navigate transitions of care - including, when appropriate, timely and compassionate hospice transitions that originate in the community rather than from a hospital bed.

• Reviews daily all Tier 1/2 signals and specialist/PCP referrals, and complete first outreach within 48 hours.
• Reviews the patient's chart before first contact, including diagnosis, specialist contacts, recent hospitalizations, medications, and advance directives.
• Builds initial trust and rapport with newly identified patients and schedule the first home or center-based assessment visit.
• Coordinates scheduling of Palliative Care provider with specialty care team members.
• Obtains verbal consent by phone and written consent at the first visit; document preferred contact methods and caregiver information.
• Confirms and documents specialist contacts (oncology, cardiology, nephrology, pulmonology) and obtains releases of information; for oncology patients referred through the CPL partnership, confirm the co-management plan with the oncology practice.

• Conducts head-to-toe assessments covering vital signs, neurological, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, skin/integument, pain, and functional status.
• Administers and scores validated clinical tools at each required interval: the Edmonton Symptom Assessment System (ESAS-r) at every visit, the Palliative Care Performance Scale (PPS) at every visit, the FRAIL Scale at initial assessment and every 90 days (or sooner with clinical change), and ECOG Performance Status at every visit.
• Complete detailed pain, nutrition and medication reviews, including a check of PRN medications available in the home, center or dwelling and confirmation the patient and caregiver know how to use them safely.
• Review and document goals of care, advance directive status, POLST/DNAR status, and healthcare surrogate or power of attorney designation at every visit; confirm family readiness before any hospice referral is transmitted.

• Determine and adjust visit frequency - face to face visits, telehealth, or phone check-ins based on the patient's Tier assignment, ECOG grade, and ESAS score, following program guidelines.
• Maintain, at minimum, weekly contact with every Tier 1 patient (a non-negotiable cadence floor) and contact with every Tier 2 patient at least every 3-4 weeks, increasing frequency as clinical presentation requires.
• Assess whether a model-generated signal warrants escalation into the panel or a return to surveillance; a fired signal obligates an assessment, not an automatic enrollment.

• Recognize and act on the two defined escalation paths to the co-located Physician/NP:
  Door 1, when a PCP, specialist, or the National Medical Director directly requests a physician-level consult; and Door 2, when the Serious Illness Care Guide own escalation criteria are met - a Tier 1 symptom unlikely to resolve at nurse level, a controlled-substance or complex prescribing decision, or a suspected hospice-eligibility determination.
• Communicate clinical changes, medication concerns, symptom scores, and goals-of-care updates to the…