Join us to make a difference when life matters most
We believe every day is an opportunity to make care more personal and life more comfortable. That’s why we offer personal care, palliative care and hospice to give people the care they need with dignity, grace, and love.
The Full-Time Advanced Illness Management (AIM) Palliative Care RN will report directly to the Director of Palliative Care. You will work with patients, their families, and other health care professionals to provide and coordinate high-quality end of life care. AIM Palliative RNs offer in-person and telephonic assessments to palliative care patients in collaboration with the interdisciplinary team. AIM Palliative RN’s primary role provides in-person assessments in private homes, assisted living facilities, and skilled nursing facilities They provide education to patients and families and work to ensure patients are comfortable in their home environment.
As a Registered Nurse / RN, you will:
- Conduct in-person/telephonic RN assessments/screenings and provides education to palliative care patients, family members or caregivers as appropriate.
- Complete Risk Stratification Assessment to identify patient support needs per established protocols as appropriate in consultation with the NP
- Observes patient visit frequency per patient individual need and risk identification
- Provide reliable education and instructions to patients and families with consistently excellent customer service bringing calm, comfort and positively to patients and families
- Consult with and educate patients/families regarding disease process, self-care techniques, end-of-life care, medications, nutrition, and dietary needs
- Communicate any findings that identify appropriate preventive and rehabilitative skilled nursing, or therapy needs to the PCP or AIM Palliative NP
- Educate patient and family on medication administration and treatments as prescribed by the nurse practitioner or physician in the plan of care
- Coordinate care with palliative team members
- Communicate change in condition, or signs and symptoms of decline to Palliative NP and/or PCP
- Support hospice referral as appropriate
- Document timely clinical records on all patients including screening/assessment findings, physician orders, progress notes, and care plans
- Support care plan development and implementation for palliative care from the initial assessment through discharge. Assessment at a minimum should include: disease-specific changes, decline or change in function, nutrition and/or cognition, inadequately controlled pain or other distressing symptoms, falls, infections or similar events, the impact of the disease burden on the patient's condition, caregiver and/or family's quality of life.
- Collaborate on development and modifications to the palliative plan of care, individualized for each patient, in consultation with the patient, family and other members of the Palliative Care Team.
- Facilitate in providing and/or obtaining care for patient when a need is identified in accordance with the Plan of Care.
- Participates in evening/weekend call as required, conducting on-call services in a clinically competent and responsive manner.
- Facilitate prescription transmission to pharmacy including controlled substances to the extent delegated and licensed, in accordance with state law. Receive laboratory results and other diagnostic tests, provide results to nurse practitioner in a timely manner. Place requests for ordered durable medical equipment as medically necessary.
- Communicate clinical findings to the nurse practitioner and/or PCP as needed, but no less than bi-weekly. Re-assess effectiveness of care plan on a regular basis and modify as needed.
- Maintain effective working relationships with supportive care team (e.g., Social Worker), as applicable, and involve team when patient's care plan warrants team participation to achieve desired outcome.
- Establish and maintain effective working relationships with those contacted in the course of work.
- Communicate and document clinical findings, treatment plan and care provided in the patient's medical record in a manner consistent with acceptable standards in order to support sound nursing practice.
