Palliative Care Nurse Navigator - Post-Acute Care

Under general administrative direction the Nurse Navigator (NN) shall be an entrepreneurial, enterprising, and inspirational leader with a strong passion in palliative care. Assess the physical and psychosocial needs of patients and their families at the start of the palliative care referral and throughout their illness trajectory. Palliative Care Navigators will meet patients and assist in care and follow up throughout the palliative care journey.o Meet with patients in the most appropriate setting inpatient or outpatient; including patient homes, assisted living facilities, or skilled nursing facilities. Provide emotional support and nursing education related to the patient’s clinical situation. Provide Consultation Recording and Summary services to patients as requested, accompanying patient to medical appointments as needed, and summarizing the consultation. Serve as a patient advocate and assist in piloting the process along the continuum with the goal of facilitating effective quality care and timeliness, resulting in improved patient satisfaction and outcomes. Informs patients of their right to execute an advanced directive, and explains relevant state laws regarding advanced directives and assist as needed. Work with a multidisciplinary team to develop and implement an up-to-date care plan. Scheduling of outpatient visits with palliative care providers Coordination with the inpatient and/or outpatient palliative care team to provide continuity of care. Document appropriate correspondence and care in patients EMR. Works to maintain and update accurate outpatient palliative care patient census. Must communicate with all members of the healthcare team on behalf of the patient. Coordinate the referrals of patients to the appropriate specialist for diagnosis or treatment. Prepare correspondence and communicate with referring agencies and primary care providers as needed to enhance continuity of care Link and assist patients and their families to appropriate national, community, hospital and medical resources including but not limited to financial counseling, social work, nutrition, Rehab, psychiatric, home health, and end of life care through hospice services. o Recognize when patient qualifies for hospice through the Medicare benefit and assist with referrals to hospice services. o Provide consultation or immediate needs assessment for hospice services in the inpatient or outpatient setting. Attend weekly interdisciplinary team meetings. Expertise to identify and implement improvement processes, and the ability to design, direct and implement improvements and programs for patients, with the aim to improve the clinical experience for palliative care and potential palliative care patients Work with marketing and outreach departments to educate the public and referring physicians and facilities on services and assist Public Relations in providing the community with palliative care education and services. Maintain personal knowledge base of available resources, both in-house and outside. Maintain and increase knowledge base on palliative care-related terms, topics, and best practices. Performs other duties as assigned within the palliative care team and within time frame specified.