Home Health Nurse

Job Description
Description
Palliative Care at Home provides home based palliative symptom assessment, treatment and ongoing goals of care discussions for patients and families facing advanced illness. The full clinical team is comprised of CHWs, NPs, nurses, social workers and physicians. The team works in collaboration with patients’ healthcare teams to provide high quality evidence based complex palliative care and chronic care management and is designed to improve symptoms and QOL, reduce caregiver burden, reduce unnecessary inpatient utilization, and facilitate hospice when appropriate. Nurses responsible for providing high quality evidence based complex, chronic care management and palliative care in patients’ homes.

Responsibilities
• Work as member of interdisciplinary team assessing and addressing the complex care needs of patients and
families facing serious illness. • Visits with an caseload of patients and families in their homes to complete guided assessments, supportmedical management, address complex symptoms, and coordinate care. • Provides supportive individual and family counselling to reduce anxiety/stress and symptoms precipitated by advanced illness and hospitalizations. • Engages patients and caregivers about goals of care, reviews advance directives, and collaborately develop treatment plans based on goals • Monitor and coordinate care plans in conjunction with the rest of the clinical care team. • Evaluates medical needs for caseload of patients, provide them direct in home care• Facilitate visits by the providers remotely as needed• Communicate plan of care to consulting clinicians and PCaH interdisciplinary teams • Educates patient/family on trajectory of illness, use of medications, assesses disease understanding• Participate in weekly IDT meeting with care team• Documentation as required • Performs other related duties as assigned

Qualifications
Required:

Graduation from an accredited Nursing program. Bachelor’s Degree in Nursing. (BSN) Associate’s Degree in Nursing (ADN) RN who is matriculated in a BSN Program with a graduation date within the year. Any Associate’s Degree in Nursing (ADN) RN with Nursing experience must be approved by the CNO
Relevant clinical competence in area of nursing practice assigned; new graduates must possess current knowledge of the nursing process and its application
Licensed as a registered nurse with current registration in New York State
Name: Basic Life Saver (BCLS) Issuing Agency: AHA
2+ years of experience managing patients with medically complex and chronic/severe illness
Experience working in interdisciplinary care teams

Preferred:

Bachelor’s degree in nursing
Palliative care/hospice experience
CPR/ACLS certification
Spanish speaking proficiency/fluency