Coordinates and facilitates referrals to Hospice care based on Hospice admission criteria, recommends alternate plans of care as appropriate, and improves access to hospice services for individuals and families with a terminal illness. Serves as on-site Hospice resource to assist facility staff that refers patients to VNSNY Hospice Care. Works with hospitals, nursing homes, NORC sites, and community-based leaders to raise awareness of hospice under-utilization and advances the Hospice program. Conducts education and meets with community groups and influencers to advance awareness of end of life care services and improve hospice utilization. Works under general supervision.
Responsibilities
Obtains and documents referral information, including current medications and treatments, physician, patient and primary care person’s agreement to Hospice evaluation visit.Evaluates patient referrals to determine appropriateness for admissions to the Hospice Program and/or other VNSNY services. Accepts or declines referrals based on admission criteria and recommends alternative plans of care as appropriate.Conducts in-facility assessments in accordance with VNSNY Hospice care admissions policies and procedures. Under special circumstances, may evaluate and admit patients to inpatient Hospice Care.Provides consultation and counseling to referrers, patients and/or families about VNSNY Hospice Care and end of life care options. Provides on-site in-services for hospital staff on Hospice Care and related topics as requested. Coordinates initial Hospice care services with the Hospice Team Coordinator, including ordering supplies, equipment, medications, infusion services, continuous care staffing, etc. as needed. Ensures that needed equipment and services are in place prior to patients’ referral for hospice care.Notifies Hospice Team of patient’s acceptance for services and provides intake data, essential medical background, preliminary care plan and medical orders.Collaborates with clinical management and staff to ensure that the needs of patient’s are being met at the time of discharge or before accepting the patient for home hospice care services. Determines insurance coverage for requested hospice services and informs patients and families of sources and extent of coverage. Interprets reimbursement and coverage issues to hospital staff and negotiates with third party payor when necessary to expedite discharge. Establishes and promotes ongoing collaborative relationships with program staff, institutional personnel, and other facilities to ensure the coordination of appropriate referrals. Acts as a liaison to patients and families during the transitional period between patient’s discharge and the initiation of Hospice Team services in the region.Participates in initial Management and Interdisciplinary Team meetings for the purpose of information exchange on patient care planning.Participates in the Hospice Continuous Quality Improvement meetings related to improved quality patient care.Provides reports of statistical data of referral and marketing activity related to the facility and hospice program and submits findings to Dir. of Community and Provider Relations.Acts as a VNSNY Hospice Care representative at institutional and community programs and functions.Participates in special projects and performs other duties, as required.
For Hospice Outreach for Patient and Provider Education (HOPE) Program only:
Promotes the HOPE program and works with health care institutions and community groups to increase awareness to hospice for patients and families in the Harlem community. Works with hospitals, nursing homes, NORC sites, and community-based leaders to raise awareness of hospice under-utilization and advances the HOPE program.Ensures that HOPE program goals and objectives are met and reports weekly on progress toward performance measures.Qualifications
Licensure: License and current registration to practice as a Registered Professional Nurse or a Licensed Social Worker or Physical Therapy in New York State required.
Education: Associate’s Degree in Nursing or Master’s degree in social work required or Bachelor’s Degree in Physical Therapy from an approved program /school required. Bachelor’s Degree in Nursing or other health related field preferred. Post-baccalaureate degree in Physical Therapy preferred.
Experience: Minimum of two years of clinical experience, preferably in a Hospice or Palliative Care Program, or Oncology services, required. Strong clinical foundation with the ability to understand and converse in clinical terminology required, particularly with non-clinicians. Ability to be persuasive, negotiate to win-win outcomes and demonstrate exceptional customer service skills required. Effective oral and written communication skills required. Proficiency in personal computer operations including MS Office applications required. Experience in sales, marketing management, administration, education and/or discharge planning preferred.
Bilingual skills may be required as determined by operational needs.
Valid driver's license may be required, as determined by operational/regional needs.