Palliative Care RN

023540 Clin Alli-Palliative Care

Position Summary:

Commonwealth Care Alliance’s (CCA)Palliative Care Team, comprised of multi-disciplinary clinicians, will provide care consultation and delivery on an on-demand basis in addition to providing scheduled non-urgent services to dually eligible CCA members, a group of individuals with significant medical, behavioral, and social complexities that require intensive support.

The Palliative teams  are comprised of nursing (RN), advance practice (NP) and Behavioral Health (LICSW)team members,

The Palliative RN reports to the Palliative Managerand is called upon to work within the interdisciplinary team to comprehensively evaluate and formulate a palliative management plan for patients needing goals of care conversation, experiencing an acute event or significant change in condition and/ or end of life management and planning. The Palliative RN provides episodic advanced serious disease management, urgent visits, promotes preventative care and wellness, pain management, and augments the provision of end of life/palliative care.

The role also includes providing input to other palliative team members, outside providers and patient s’ care teams on key care management/care coordination decisions, including the adjustment of the patient-centered care plan and identification of the need for durable medical equipment and services, consideration forre-stratification and planning for end-of-life location.

Supervision Exercised:

• No, this position does not have direct reports. 

Essential Duties & Responsibilities:

• Performs episodic urgent and scheduled medical visits for palliative s to ensure that theyare given timely and appropriate medical care regarding symptom management and education about disease trajectory as well as options available in order to avoid unnecessary emergency room visits or hospitalization. Visit includes a detailed history of present illness, review of systems, medication reconciliation, physical exam, recommendations in consultation with NP/PA or physician before reaching out to outside providers. Reviews appropriate studies and tests, developssa t plan of care, and shows evidence of follow-up through timely documentation according to policy at CCA.

• Facilitates and/or delivers palliative care to patientsaccording to the guidelines deemed appropriate by CCA Palliative Leadership. Guidelines may vary based on the patient’s goals of care, as CCA offers concurrent care for patients withserious illness.

• Identifies and initiates a plan to resolve areas of opportunity to meet quality and operational metrics.

• Provides regularly scheduled follow-up visits for patients facing end of life/and palliative care. Visits are inclusive of a history of present illness, review of systems, physical exam, medication reconciliation, recommendations in consultation with supervising NP or MD for ordering of appropriate studies or tests, adjustment, or maintenance of an established treatment plan, and consistent follow up of the plan as evidenced in the documentation.

• Documents all activities and results using an Electronic Medical Record, in an effective manner while strictly adhering to CCA policies and procedures

• Adjusts the patient-centered plan of care as necessary based on a significant change in condition. A change in condition is an event (hospitalization, acute illness, etc.) which results in either a short- or long-term change in need

• Utilizing and depending on CCA internal resources, ensures that the plan of care is implemented in a timely manner.

• Provides end of life care to a panel (in coordination with Care Partners) in a manner that is consistent with helping the patient and caregiver identify goals of care, anticipate changes needed as patient’s condition declines along the disease trajectory.

• Helps patient and caregiver navigate end of life decisions related to goals, incorporating realism and safety in a way that

• also empowers them to make the decisions that are best for them.

• Shows an ongoing commitment to learning about the tenants of Palliative Care through ongoing pursuit of education and obtaining certification if not already certified in hospice and palliative care.

• Provides clinical care to patientsvia telehealth technologies (video, chat, etc.) for a clinically appropriate clinical care and care management services.

• Outreach to existing clinical partners promoting and educating about Palliative Care

• Participates in cross-organizational working groups to continuously improve team performance as requested.

• Identifies and suggests improvements to clinical programs, initiatives, processes, policies, workflows, and projects.

• Participates in CCA Quality Improvement efforts.

• Participates in committees and workgroups that promote clinical excellence and help to advance CCA’s mission and business objectives as requested

• Provides coaching and mentorship to new employees as requested by CCA Palliative Leadership

• Other projects and requests made by Palliative Manager

Working Conditions:

• Must be willing and able to travel to member’s homes\

• Valid driver’s license with no restrictions.

• Ability to be active and mobile across MA.

Required Education:

• Associate degree in Nursing

Desired Education:

• Associate, Bachelor, or master’s degree from an accredited school of Nursing

• Certification in Hospice and Palliative Care strongly preferred

Required Licensing:

• RN licensure in good standing in Massachusetts

Required Experience:

• 3+ years in Medical Surgical, VNA or Hospice setting

• Experience working with Medicare /Medicaid populations or populations with significant complexity of medical, behavioral and social needs.

Desired Experience:

• Experience with electronic medical records preferred

Required Knowledge, Skills & Abilities:

• Demonstrate clinical competence in aspects of care management, assessment, care planning, and medical/surgical treatment

• Excellent interpersonal skills demonstrated by ability to interact professionally with culturally and educationally diverse staff and patients

• Ability to manage significant change

• Excellent communication skills

• Ability to teach, mentor, and coach

• Ability to quickly shift gears and move in a new direction without clear guidance

• Willing to learn and utilize telehealth technologies (video, chat, etc.), when appropriate, for a variety of clinical care and care management services.

Language(s):

• Fluency in English required

• Fluency in one or more of the following languages strongly preferred: Spanish, Portuguese, Russian, Nepalese, and Vietnamese

Other:

• This position will utilize standard office equipment, including a Cell Phone.

• Physical Requirements:

• 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; use hands to finger, handle, or feel; reach with hands and arms; and talk or hear

• The employee is occasionally required to walk; sit; and stoop, kneel, crouch, or crawl

• The employee must frequently lift and/or move up to 10 pounds and occasionally lift and/or move more than 100 pounds

• Specific vision abilities required by this job include close vision, distance vision, and ability to adjust focus