Transitional Care Nurse

DescriptionThe Transitional Care Nurse provides direct nursing care to patients, care coordination and education to patients, families and staff in general inpatient units in accordance with established policies, procedures, and protocols. This position involves patient assessment, establishment of an individualized plan of care, discharge planning and communication with the hospice physician to meet patient/caregiver needs.RESPONSIBILITIES:Completes general inpatient (GIP) admissions, collaborating with the hospital physician and the Hospice physician to assist in determining the patient’s clinical eligibility for hospice careMakes visits to assess GIP patients daily while patient is in the hospitalParticipates and plans discharge for those GIP patients that will be transitioned home with hospice, assisting with and completing appropriate paperwork as neededProvides education regarding home hospice care and home palliative care to patients that are in the hospitalProvides education to the hospital staff regarding hospice and palliative careImplements and monitors patient care plansMonitors, records and communicates patient condition as appropriateServes as primary coordinator of all disciplines for well-coordinated patient careParticipates in bi-weekly interdisciplinary group (IDG) meetingsAssesses needs of patient and family and provides education and support based on age, culture and willingness to learnPerforms home hospice admissions as neededPronounces patients and performs other routine nursing visits when requestedParticipates in Quality Assessment Performance Improvement (QAPI) program and Hospice sponsored in-servicesPerforms job duties in accordance with Nurse Practice ActOther duties as assignedRequirementsLicensed as a registered nurse in the state of GeorgiaGraduate from an accredited school of nursingMinimum of five (5) year’s nursing experienceMinimum of two (2) years’ experience in hospice/home care preferredCertified Hospice and Palliative Care Nurse (CHPN) preferredCritical thinking skills and decisive judgment requiredWorks under minimal supervisionAbility to work in a stressful environment requiredGood verbal and written communication and problem-solving skills requiredResponsible valid driver’s licenseReliable, insured, automobile for making home visits required

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