APRN - Palliative Care Home Visit Service

Lee County, FL

Summary

The Palliative Care Home Visit Nurse Practitioner is responsible, as part of the patient centered care team, for the overall patient care management process, with a focus on pain management, anxiety reduction, comfort measures, emotional support for patient and family, and end of life advanced care planning. An advocate for the patient, the Nurse Practitioner will provide total care for the patients assigned in collaboration with the physician of record, pain management physician, Hospice team when applicable, and all members of the patient care team. The Nurse Practitioner will communicate and manage the patients' care across all care providers, family, and caregivers. The Nurse Practitioner will ensure that timely, patient-centered, appropriate evidence-based palliative care medicine is provided. The Nurse Practitioner will assist in addressing outstanding quality measures and HCCs, as applicable, to meet or exceed all quality goals. The Nurse Practitioner will be responsible for ongoing communication with the primary care provider, palliative care nurse case manager, social worker, clergy, and other members of the patients care team, to provide for the patients physical, psychological, emotional, mental, and spiritual needs and to ensure continuity and coordination of care. The Nurse Practitioner will complete all documentation and billing in a timely manner, per protocol. The Nurse Practitioner will be responsible for other duties as assigned.

Essential Duties and Responsibilities include the following. Other duties may be assigned.

• Is responsible for the total care of all assigned patients in collaboration with the community-based physician/provider and patient care team.
• Is responsible for patient assessments and palliative care planning, initiating and assistance with advanced directives, identifying spiritual, psycho-social, and financial needs and seeking appropriate intervention, addressing quality measures and HCCs, and providing palliative comfort and end of life care, within their scope of practice.
• Provides services to meet patient needs and prevent unnecessary Emergency Department utilization when appropriate. In home services include but are not limited to: IV hydration, collaboration with Pain Management Physician for adequate pain management, lab draws, nebulizer treatments, EKGs, wound care, and injections, and utilization of mobile diagnostics as indicated.
• Ensures all pertinent and active medical conditions are documented in the electronic medical record in a timely manner, consistent with MPG policy, and in a compliant manner with CMS and other insurance carriers.
• Exhibits strong clinical skills to improve patient care for an aging, adult population; as well as excellent interpersonal relationship skills in interpreting and communicating health care information to the patient, family, and Patient Care Team.
• Provides leadership in the application of the nursing process to client care, organizational processes and/or systems improving outcomes at the program or service level and initiates interdisciplinary projects to improve organizational performance.
• Identifies patients who are appropriate and would benefit from Skilled Nursing/Therapy and initiates the SNF 3 Day Waiver for MACO qualifying patients. Follows all CMS guidelines and ensures patient is admitted to a qualifying SNF. Completes all required documentation and works with SNF Case Manager and other members of the health care team to ensure continuity and patient safety.
• Accountable for identifying patients needing additional assistance and making referrals to Home Care, Social Services, Behavioral Health, Hospice, Spiritual Care, and other available community resources, when needed and appropriate.
• Responsible for direct oversight of assigned Medical Assistant. Reports to and works collaboratively with Program Director to establish workflow processes, provisions of ongoing education/training, and employee improvement planning as needed.

Competencies:

To perform the job successfully, an individual should demonstrate the following competencies:

Analysis/Problem Assessment - Securing relevant information and identifying key issues and relationships from a base of information; relating and comparing data from different sources; identifying cause-effect relationships.

Compassion - The responsibility to put a patient's or person's interests first, including the duty not to harm, deliver proper care, and maintain confidentiality.

Compliance - Employee has satisfactory completed employers required compliance training. Employee is able to demonstrate an understanding of employers Code of Conduct.

Communication - Expressing ideas effectively in individual and group situations (including nonverbal communication); adjusting language or terminology to the characteristics and needs of the audience. Good listening skills.

Dependability - Meets commitments, deliverables, deadlines, work independently, accepts accountability, handles change, sets personal standards, stays focused under pressure, and meets attendance/punctuality requirements.

Individual Leadership/ Influencing - Using appropriate interpersonal styles and methods to inspire and guide individuals (fellow employees) toward goal achievement; modifying behavior to accommodate tasks, situations, and individuals involved.

Innovation - Generating creative solutions to work situations; trying different and novel ways to deal with organizational problems and opportunities.

Integrity - Maintaining and promoting social, ethical, and organizational norms is conducting internal and external business activities.

Judgment/ Problem Solving - Recognizes problems and responds, systematically gathers information, sorts through complex issues, seeks input from others, addresses root cause of issues, makes timely decisions, can make difficult decisions, uses consensus when possible, and communicates decisions to others.

Maximizing Performance - Establishing performance/development goals, coaching performance, providing training, and evaluating performance.

Organizational Awareness - Having and using knowledge of systems, situations, procedures, and culture inside the organization to identify potential organizational problems and opportunities; perceiving the impact and the implications of decisions on other components of the organization.

Patient Service Orientation - Proactively developing patient/customer relations by making efforts to listen and understand the customer and their needs (both internal and external); anticipating and providing solutions to customer needs; giving high priority to patient/customer satisfaction. Ensures appropriate follow up and is their advocate in determining solutions. The employee uses a variety of communication techniques to effectively express thoughts and ideas and to understand or influence.

Planning and Organizing/ Work Management - Establishing a course of action for self to accomplish a specific goal; planning proper assignments of personnel and appropriate allocation of resources.

Results Driven & Execution - Accountable for meeting or exceeding individual and/or department goals and objectives. Committed to producing results that will achieve company objectives. Sets priorities and organizes time to meet or exceed goals, follows up, and takes personal responsibility for results whether they are positive or negative.

Teamwork/ Collaboration - Working effectively with team/work group or those outside formal line of authority (e.g., peers, senior managers) to accomplish organizational goals; taking actions that respect the needs and contributions of others; contributing to and accepting the consensus; subordinating own objectives to the objectives of the organization or team. Listens to others and values opinions.

Work Standards - Setting high goals or standards of performance for self, direct reports, others, and the organization; being dissatisfied with average performance; self-imposing standards of excellence rather than having standards imposed by others.

Qualifications To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and/or Experience - Completion of master's degree in nursing; two years' experience.

Language Skills - Ability to read, analyze, and interpret the most complex documents. Ability to respond effectively to the most sensitive inquiries or complaints.

Mathematical Skills - Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.

Reasoning Ability - Ability to define problems, collect data, establish facts, and draw valid conclusions. Ability to interpret an extensive variety of technical instructions in mathematical or diagram form and deal with several abstract and concrete variables.

Computer Skills - To perform this job successfully, an individual should have knowledge of Athena Database software; Microsoft Spreadsheet software and Microsoft Word Processing software; including Excel.

Certificates, Licenses, Registrations: Advanced Registered Nurse Practitioner

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this Job, the employee is regularly required to stand; walk; use hands to finger, handle, or feel; reach with hands and arms; climb or balance and talk or hear. The employee is frequently required to sit. The employee is occasionally required to stoop, kneel, crouch, or crawl. The employee must occasionally lift and/or move up to 10 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. In Home patient visits is a requirement of this position. While performing the duties of this Job, the employee is exposed to outside weather conditions and patient's home environment.