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RN - Hospice Hospital Liaison

Company: Sutter Health System
Location: Santa Rosa
Posted on: September 11, 2018

Job Description:

The Sutter Care at Home Hospice Liaison facilitates admissions to Sutter Care at Home services by providing inpatient supportive care and seamless transition to home based care. The Hospice Liaison assists the organization by assuring that the right care is provided at the right place and the right time. The Hospice Liaison positively promotes Sutter Care at Home (SCAH) as the home care provider of choice within the communities for hospice services. The Hospice Liaison will help market SCAH as the hospice organization of choice. The Hospice Liaison will serve as a resource by supporting the mission and vision of the organization.

To accomplish this goal of right care, right place and right time, the Hospice Liaison uses established criteria to:
a) evaluate the appropriateness of patients referred for hospice services
b) confirm the level of care most appropriate for the patient
c) assess the patients readiness for discharge
d) facilitate transition to home planning including assessing post-discharge needs and developing and implementing transition to home plan

Holding continuity of care as a priority, the Liaison communicates and coordinates with the larger health care team supporting the patient including hospitalist, hospital case management and nursing, patients physicians, and other healthcare providers involved in the patients care at home. The Liaison will attend rounds, facilitate orders, evaluate patients' care (medical, psycho-social and practical) needs, including medical eligibility for services, anticipated needs for equipment, medication, and transportation.

The Liaison collaborates with the patients and their representatives, the patients' inpatient care teams, and outpatient care teams to identify patient/family needs and preferences as well as the overall care needs. The Liaison is responsible for helping the patients and their representatives determine person-centered goals.

The Liaison possess critical thinking skills, in-depth knowledge of clinical disease entities common to hospice.

The Liaison serves as a clinical resource for patients, families, physicians, and facility staff for appropriate home placement, medication reconciliation, goals of care and identification of necessary support at home, as well as problem solving barriers or challenges related to the patient returning home.

Current California RN license; valid California drivers license; current auto insurance; current BCLS/CPR certification.
Bachelor's degree desired.

--- Minimum of two years experience in Hospice setting within last five years
--- Minimum 3 years in nursing experience required.
--- Must have direct patient care experience within the last five years
--- Recent experience in acute-care hospital setting; knowledge of discharge planning/case management strongly preferred.

--- Must have strong clinical knowledge of disease entities common to hospice
--- Must have critical thinking skills with the ability to create a viable and effective patient transition plan and identify barriers in service, effectively conduct verbal or written patient assessments, carry out the referral process, and coordinate with other individuals involved in the plan of care.
--- Understanding of hospice services and regulations, Medicare Conditions of Participation, reimbursement systems.
--- Knowledgeable about disease states and prognosis and how illness progresses clinically and functionally.
--- Knowledgeable of how hospice services can help patients and families at the end of life care.

--- Ability to communicate and be open in a group setting and a one-on-one conversation
--- Self-starter with a high degree of initiative, motivation, flexibility, energy and creativity.
--- Ability to work as part of a team as well as form harmonious working relationships with internal and external customers.
--- Excellent collaborative and problem solving skills with customers and management.
--- Excellent organizational skills.
--- Must have excellent telephone, interpersonal and written communication skills.
--- Strong commitment to teamwork and customer service, both internally and externally, is required.
--- Experience with Microsoft Office suite and electronic health record strongly desired.
--- May be asked to work in field providing homecare services as per changes in business needs and as skills and training allow.
--- Must be able to develop an organized work plan in a high-volume environment with rapidly changing priorities.

Primary Location: California, North Bay/Lake County, Santa Rosa
Organization: Sutter Care at Home
Employee Status: Regular
Benefits: Yes
Position Status: Non-Exempt
Union: No
Job Shift: Day
Shift Hours: 8 Hour Shift
Days of the Week Scheduled: Monday-Friday
Weekend Requirements: Other
Schedule: Full Time
Hrs Per 2wk Pay Period: 80

Keywords: Sutter Health System, Santa Rosa , RN - Hospice Hospital Liaison, Healthcare , Santa Rosa, California

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