• Collaborate with physicians and other professionals to plan care
• Make frequent visits to the patient to evaluate their condition
• Provide support and comfort according to the individual patient’s needs
• Work with caregivers to plan and execute excellent patient care
• Help in administering medication
• Alleviate sudden symptoms of the disease’s end phase
• Notify a doctor for a patient’s condition when deemed necessary
• Assist patients and their families with paperwork
• Maintain accurate and up-to-date records
• Help relatives cope with the upcoming loss and provide post-mortem support

Skills: Patient Care Coordination, Symptom Management, Medication Administration, Emotional Support, Caregiver Collaboration, Medical Documentation, Crisis Intervention, Bereavement Support

• Serves as the primary care nurse for all assigned cases and provides skilled nursing services.
• Observe, evaluate, and report to the attending physician and interdisciplinary team the patient's physical and emotional conditions and reactions to drugs or treatments.
• Interprets the social, cultural, and physical factors in the environment that affect patient care.
• Assists in developing a pain management and symptom management plan to keep the patient as comfortable 
• Reassess pain and notify the primary care physician when pain is not manageable on the current medication.
• Develops a patient care plan utilizing the written physician's orders, communicates and interprets the goals of care to the patient and family.
• Completes written documentation for the medical record, assists the family to accept the responsibilities for providing care in the home, and provides emotional support for these activities.
• Recognizes attitudes, religious beliefs, and cultural patterns that are significant to the patient's care and adapts the approach accordingly.
• Supervises hospice aides.

Skills: Nursing Care Delivery, Patient Assessment, Pain Management, Care Plan Development, Medication Evaluation, Family Education, Cultural Sensitivity, Hospice Supervision

• Participate in Interdisciplinary Team (IDT), manage and coordinate the beneficiary and family/caregiver Plan of Care from referral to discharge.
• Facilitate communication about changes in the beneficiary’s status among IDT members and the beneficiary’s attending physician.
• Plan, coordinate, and deliver direct nursing care to beneficiaries and families according to the beneficiary’s needs.
• Visit each beneficiary at least every 14 days by regulatory requirements.
• Participate in the coordination of care activities with families, physicians, and host nursing facility partners, such as care coordination meetings, at-risk meetings, information presentations, or meet-and-greets.
• Perform an initial and comprehensive assessment of the beneficiary/family and develop a Plan of Care and ensuring the care plan is up to date and reviewed at every team meeting.
• Notify the physician and/or appropriate others of significant findings or changes in the beneficiary’s physical or mental condition.
• Consult with physicians regarding the care of the beneficiary as changes in the beneficiary’s POC occur 
• Assess beneficiary needs for necessary therapies (PT, OT, and ST) and consult to assist in quality of life and comfort care.

Skills: Interdisciplinary Collaboration, Care Plan Management, Direct Patient Care, Status Communication, Comprehensive Assessment, Physician Consultation, Family Coordination, Therapy Assessment

• Complete the Hospice Aide schedule each week and provide SNF/caregivers with copies of the schedule. 
• Communicate all schedule changes as soon as they are made.
• Supervise and document Hospice Aide Plans of Care and document supervisory visits.
• Participate in the on-call nursing rotation schedule.
• Make every effort to attend deaths of beneficiaries to assist and support the family/caregiver.
• Timely documentation by regulations.
• Update and maintain medical records of Fidelis beneficiaries.
• Maintain a regular program of professional development by attending staff development programs and training related to current nursing practices.
• Follow standard precautions and infection control procedures at all times.
• Attend and participate in all in-service trainings and meetings 

Skills: Schedule Coordination, Change Communication, Aide Supervision, On-Call Support, Family Assistance, Timely Documentation, Medical Records Management, Infection Control

• Admits hospice patients, which includes performing an assessment, planning, intervention, and evaluation.
• Performs patient assessments, obtains vital signs and appropriate data, evaluates data, and intervenes 
• Implements patient care plans, administers medications and intravenous solutions, records observations, and maintains records and reports. 
• Maintain an accurate record of controlled substances and all medication given to each patient.
• Utilizes the nursing process to make recommendations for patient care
• Evaluates delivery of patient care and communicates to appropriate personnel relevant facts about patients, actions taken, and patient responses.
• Educates the patient and/or family on services provided and on the physician's orders.
• Provides ongoing assessment of patient response to treatments, medications, and teaching, and applies interventions 

Skills: Patient Admission Assessment, Care Plan Implementation, Medication Administration, Record Keeping, Nursing Process Application, Patient Evaluation, Family Education, Treatment Monitoring

• Updates and revises the care plan 
• Follows agency and medical policies, emergency orders, and nursing procedures.
• Directs the care given by the Nursing Assistants, Licensed Practical Nurses, and volunteers.
• Participates in chart audits and continuous quality improvement activities.
• Communicates with physicians to confirm and update the patient's plan of treatment. 
• Contact physicians for patient symptom management.
• Provide care appropriate to the age of the patients served.
• Facilitates the patient and family's right to receive quality, cost-effective care.

Skills: Care Plan Revision, Policy Compliance, Staff Supervision, Quality Improvement, Physician Communication, Symptom Management, Age-Appropriate Care, Patient Advocacy

• Assesses patient/family for physical, psychological, social, and spiritual needs and collaborates with patient/family, physician, and IDG to establish the plan of care, implement interventions, and/or evaluate care
• Initiates and maintains communication with attending physician, Medical Director, IDG, Team Director, Team Manager, and/or other agencies to coordinate optimal care and use of resources for the patient/family
• Documents according to protocol and maintains up-to-date patient records so that the care plan's problems, interventions, actions, and goals reflect baseline, current, and ongoing status, and changes as they occur
• Participates in On-Call or Admissions assignment/rotation 
• Provides education to patients and caregivers based on knowledge needs and learning assessment, and patient/family condition
• Coordinates care with IDG and informs the Team Director/Team Manager and IDG of unusual or potentially problematic patient/family issues
• Participates in orientation and ongoing education programs and maintains current professional licensure
• Uses agency and states policies and protocols about the provision of hospice and nursing services to meet internal process requirements and state/federal regulations
• Participates in IDG Meetings, facility patient conferences, and other patient/family meetings in coordination with IDG and /or Team Director
• Proactively manages using the Case Management Recipe to coordinate all patient care activities in collaboration with IDG

Skills: Needs Assessment, Care Coordination, Patient Documentation, On-Call Support, Patient Education, Issue Resolution, Professional Development, Policy Adherence

• Scheduling patient visits by needs, physician collaboration, orders management, medication management, Plan of Care coordination, etc, to assure continuity and quality of care and coordinated IDG efforts
• Supervises LPNs/LVNs/Hospice Aides per protocol, On-Call
• Perform Admissions, GIP, CC, and routine visits as assigned
• Responds to the Triage Nurse to receive patient status information and coordinate follow-up up including visit activity, coordinating med refills and physician orders, and phone support
• Coordinates schedule and care activities with AOC 
• Evaluates patient status  for routine and emergent visits utilizing telephonic, telemedicine, and/or in-person evaluation
• Provides support for the Pre-Hospice patient and family as new medical needs are identified or questions arise, with referral to other clinicians 
• Contributes to the ongoing care planning process, especially regarding medical needs, with the care team and other agencies
• Evaluates patient for other appropriate services to best meet patient needs
• Collaborates with the entire care team, alerting them to changes and newly identified patient needs

Skills: Patient Scheduling, Physician Collaboration, Orders Management, Medication Management, Team Supervision, Triage Coordination, Status Evaluation, Care Planning

• Ensures compliance with applicable licensure/certification requirements, applicable healthcare standards, governmental laws and regulations, and HHCAH policies and procedures.
• Abides by and demonstrates H3W Leadership Behaviors and continued process improvement through job performance on a day-to-day basis.
• Proficient performance with case management, all OASIS time points, and skilled nursing revisits to clinicians during the orientation process.
• Proficient use of SHP to determine trends, educational opportunities, and to provide feedback to clinicians.
• Observes clinical skills and patient interaction of new clinicians and provides feedback to the clinician.
• Works with clinicians to review the application of clinical documentation and forms.
• Reviews the Orientation process with the Clinical Development Specialist to determine the clinicians’ level of understanding and need for reeducation
• Reviews patient care processes with clinicians and assesses clinicians’ level of understanding.
• Meets with new hire regularly to assess progress.
• Meets with Clinical Development Specialist and Clinical Team Managers regularly to discuss the progress of the new hire.
• Serves as a mentor to new clinical hires to include regular discussions each month for a minimum of one year.
• Maintains/enhances clinical practice skills by attending, participating in/conducting staff development/ continuing education programs.

Skills: Regulatory Compliance, Process Improvement, Case Management, Clinical Feedback, Documentation Review, Staff Mentoring, Orientation Assessment, Skill Development

• Meets all standards of the Patient Satisfaction Initiative Criteria to make AMH the hospital of choice for Patients and Employees
• Supports the department of Home Care/Hospice philosophy, objectives, and policies and interprets them for the patient, family, significant others, physicians, and other health care team members to promote understanding of the nursing process.
• Implements and evaluates care knowledgeably and skillfully through the use of adherence to pre-determined standards to assist patients toward desired outcomes
• Systematically performs observation/data collection to identify patient care and educational needs.
• Formulates a goal-directed plan of care based on nursing diagnosis and patient outcomes to serve as a communication tool for all nursing personnel.
• Documents care provided to comply with the Medicare Conditions of Participation, Standards of Nursing Practice, and legal, regulatory, and insurance requirements.
• Collaborates with other members of the health care team in preparing the patient/family for the achievement of end of end-of-life goals or discharge
• Contributes to the professional development of self, peers, and colleagues to support staff development and quality improvement projects.
• Assist in facilitating departmental operations.

Skills: Patient Satisfaction, Policy Interpretation, Care Implementation, Data Collection, Goal Setting, Care Documentation, Team Collaboration, Staff Development

• Experience in direct patient care in medical-surgical nursing
• Current RN licensure in the appropriate state
• Ability to provide direct patient care, demonstrate excellent nursing skills
• Excellent verbal and written communication skills, problem-solving skills, and basic math skills
• Understanding of hospice philosophy and issues of death/dying, and demonstrates competency in pain and symptom management with EOL care
• Ability to interpret information to identify each patient’s requirements for care relative to his/her age-specific needs
• Ability to prioritize, organize, and handle varying and unpredictable situations such as emergencies or crises
• Must be flexible, versatile, adaptable to change, with good critical thinking, problem-solving, and diplomacy skills
• Must be available for after-hours call on a rotational basis

Qualifications: BS in Nursing with 2 years of Experience

• Knowledge of procedures and nursing standards of practice, both general and specific to the specialties of medical-surgical nursing
• Previous home care or hospice experience
• Ability to interact effectively with diverse individuals at all levels of authority, in teams, and on committees
• Ability to actively identify new areas for learning
• Be able to regularly create and take advantage of learning opportunities
• Ability to use newly gained knowledge and skills on the job and learning through their application
• Must have computer experience and have reliable transportation to and from all work-related assignments and activities
• Must be flexible to travel between different locations, as assigned, in all weather conditions and on roads in varying degrees of repair
• Be able to specific vision abilities include close vision, distance vision, night driving, and the ability to adjust and focus.

Qualifications: BS in Health Sciences with 3 years of Experience

• Current and unencumbered license as a Nurse Practitioner in the state where the employee is assigned to work by the Company.
• Experience as a Nurse Practitioner and experience as a hospice Registered Nurse 
• Must meet the training, education, and experience requirements to be authorized to practice as a nurse practitioner in the state where services are provided, including, without limitation, being certified as a Nurse Practitioner by a recognized national certifying body that has established standards for nurse practitioners.
• Must have the authority to practice as a nurse practitioner in the state where services are provided.
• Must have obtained Medicare billing privileges as a nurse practitioner.
• Must meet physician-nurse practitioner restrictive collaborative requirements specific to the state assigned to work by the Company and supply a copy of all active collaborating physician agreements and indicate whether these will be transferable to employment with Amedisys.
• Must have insurance required by state law for nurse practitioners to practice and prescribe in the state where services are provided, or be eligible for such insurance requirements to be satisfied by group coverage with an employer
• Knowledge of Medicare reimbursement and coding for all levels of service, such as home, office, nursing home, assisted living, etc., Medicaid, and other regulatory requirements.
• Current CPR certification.
• Familiarity with Electronic Medical Record.
• Knowledge of and experience with caring for the geriatric patient.
• Previous experience in geriatric primary care
• Previous experience and education in palliative care
• National certifications in the field of expertise
• 
  
• Qualifications: BS in Palliative Care with 1 year of Experience

• Current State License as a Registered Nurse
• Certification as a Nurse Practitioner.
• Experience  in chronic disease management/long-term care
• Must have a strong Hospice background
• Nursing skills by accepted nursing standards
• Demonstrates ability to assess and respond to the needs of patients, families, and caregivers in varied settings and to function effectively in the home or nursing facility environment
• Demonstrates skill in nursing practice, ability to cope with family emotional stress, and tolerance of individual lifestyles
• Ability to handle multiple priorities, documentation requirements, and deadlines.

Qualifications: BS in Biology with 2 years of Experience

• Proven experience as an LPN or similar role
• Ability to undertake a variety of diverse care tasks and work in a multidisciplinary team
• Familiarity with hospital health, safety, and sanitation standards and procedures
• Understanding of confidentiality obligations and nursing best practices
• Excellent knowledge of medical and hospital terminology
• Good knowledge of MS Office and data entry
• Perfect physical condition and stamina
• Excellent communication and interpersonal skills
• Compassionate and able to handle stress
• Successful completion of the LPN license program is a must
• Experience with a negative TB test or chest x-ray
• Must adhere to HIPAA and maintain client confidentiality

Qualifications: BS in Public Health with 4 years of Experience

• Current RN licensure in the state of practice, successful completion of a nursing education from an approved school of nursing, with clinical nursing experience, and hospice nursing experience
• Knowledge of the framework, function, and organization of a home health and hospice care program and the nurse’s role as a member of the patient care team.
• Working knowledge of the principles and practice of nursing according to the nursing practice act, agency policies and procedures, and reimbursement guidelines.
• Must hold CPR certification.
• Willing to accept travel based on agency need, as well as weekend/evening, and holiday call assignments.
• Must be a PA-licensed Registered Nurse
• Experience in hospice or home care
• Must be compassionate and willing to go the extra mile for patients and their families
• Previous nursing experience

Qualifications: BA in Psychology with 6 years of Experience

• Currently licensed in the state of Massachusetts as an LPN
• Must meet the Hospice's conditions of employment regarding health clearance and provisions of professional references.
• Ability to read, write, and speak English.
• Be able to function in a practice environment with minimal direct supervision, accepting personal responsibility for maintaining a professional relationship with patients and families.
• Ability to relate to and treat terminally ill patients/families.
• Ability to function in the home situation regardless of age, race, creed, color, sex, disability, or financial condition of the patient.
• Absolute integrity and the use of good judgment to handle the professional and confidential nature of assignments.
• Ability to use Microsoft Office Suite effectively (Outlook, Word, Excel)

Qualifications: BA in Social Work with 1 year of Experience

• Registered Nurse license required in states practicing
• Current and valid CPR certification
• Previous experience in hospice, home health, general medical-surgical, or patient population-specific (i.e., geriatrics, pediatric, etc.) nursing.
• Willingness to serve on-call
• Must meet the regulations and requirements of the State in which the program provides services
• Must be committed to AccentCare's philosophy of care, TRUE HOPE values, vision, and mission statements as an exemplary role model for all staff
• Ability to cope with family emotional stress and tolerance of individual lifestyles
• Strong communication and interpersonal skills

Qualifications: BS in Gerontology with 8 years of Experience

• Acute clinical nursing experience or home health experience, and hospice nursing experience 
• Must be a licensed driver with an automobile that is insured following state and/or organization requirements and is in good working order.
• Must have current licensure as a Registered Nurse in the State of California.
• Must have current BLS certification before clinical rotation.
• Licensed Registered Nurse in the State of Massachusetts
• Sensitivity and understanding of end-of-life issues
• Experience in community health, hospice, and oncology.
• Demonstrated assessment skills for pain management and symptom control
• Excellent organizational and time management skills
• Exceptional communication skills

Qualifications: BS in Human Services with 3 years of Experience

• Clinical experience as a Nurse Practitioner in a geriatric, adult, or family practice setting. 
• Ability to perform a comprehensive, adult/geriatric physical exam.
• Board certification by AANP or ANCC, in Adult, Family Practice, and Geriatrics or Adult-Gerontology Primary Care. 
• Previous long-term care experience 
• Must have experience in hospice, home health, oncology, or medical-surgical nursing.
• RN (Registered Nurse) license in the state where practicing.
• Current Cardio Pulmonary Resuscitation (CPR) certification 
• Demonstrated commitment to Seasons Hospice’s philosophy of care, values, mission statement, and organizational culture

Qualifications: BS in Clinical Medicine with 2 years of Experience