Job Summary: 

• Maintains a working knowledge of standards of care for hospice programs to ensure compliance with Medicare certification and state licensure of the hospice program
• Completes documentation, including assessments, certifications, and care plans, by the Medicare Conditions of Participation for hospice programs.
• Attends and participates in IDG, mandatory staff meetings, and in-service programs.
• Maintain communication and provide updates or changes in patient condition to the patient's family, primary care physician, facility staff, and hospice medical director.
• Monitors quality end-of-life care by routinely assessing patients' needs
• Completes accurate documentation and coordinates care with other members of IDG
• Provide end-of-life education for patients, family members, caregivers, and friends
• Responds to the physical, mental, social, and emotional needs of the terminally ill patient and their loved ones.

Skills on Resume: 

• Hospice Care Knowledge (Hard Skills)
• Medicare Compliance (Hard Skills)
• Clinical Documentation (Hard Skills)
• Team Communication (Soft Skills)
• Patient Monitoring (Hard Skills)
• End-of-Life Education (Soft Skills)
• Compassionate Support (Soft Skills)
• Care Coordination (Hard Skills)

Job Summary: 

• Revises/updates care plans and performs assessments of family/caregiver needs on an ongoing basis.
• Pronounces death in the absence of a physician and makes all appropriate notifications
• Complete all required documentation.
• Assess, administer, and document professional nursing care to assigned Hospice patients utilizing the nursing process by both the nursing and administrative policies.
• Performs patient care responsibilities in an environment that optimizes patient/caregiver safety and reduces the likelihood of medication/healthcare errors
• Understand medications and their correct administration
• Coordinates all patient services
• Assesses pain and utilizes appropriate pain management
• Offers support and palliative care.

Skills on Resume: 

• Care Plan Updates (Hard Skills)
• Death Pronouncement (Hard Skills)
• Documentation (Hard Skills)
• Nursing Assessment (Hard Skills)
• Patient Safety (Hard Skills)
• Medication Knowledge (Hard Skills)
• Service Coordination (Hard Skills)
• Pain Management (Hard Skills)

Job Summary: 

• Coordinates the interdisciplinary care team for assigned patients and is designated to coordinate the implementation of the plan of care.
• Provides the primary nursing care for hospice patients, regardless of the setting.
• Assumes full responsibility for the professional management of assigned hospice patients’ care related to the patient’s terminal illness.
• Teaches the primary caregiver skills that are needed to care for the patient in their residence.
• Works closely with the attending physician and other team members to develop appropriate pain and symptom management.
• Completes nursing assessments and admissions of patients.
• Maintains the clinical record to meet federal, state, and agency regulations and guidelines.
• Supervises hospice aides and certified nurse aides, making a supervisory visit at least every 14 days, and face-to-face at least monthly.
• Assumes all on-call responsibilities 

Skills on Resume: 

• Team Coordination (Hard Skills)
• Primary Care (Hard Skills)
• Case Management (Hard Skills)
• Caregiver Teaching (Soft Skills)
• Symptom Management (Hard Skills)
• Nursing Assessment (Hard Skills)
• Record Maintenance (Hard Skills)
• Staff Supervision (Soft Skills)

Job Summary: 

• Participates in the Performance Improvement Program.
• Participates in and presents in-service programs, team conferences, and staff meetings.
• Provides skilled nursing care to assigned patients/families as outlined in the plan of care.
• Participates in the development of the patient/family interdisciplinary care plan.
• For patients residing in a skilled nursing facility, manage the patients’ symptoms related to the terminal illness.
• Verify by patient visit and review of documentation that the caregivers in the SNF are carrying out the plan of care as written.
• Have ultimate responsibility for developing and integrating the plan of care with the hospice team and the SNF team to assure one integrated plan of care that reflects the hospice philosophy.
• For patients receiving private home care services, supervise the certified nursing aides, sitters, and companion services assigned to patients.

Skills on Resume: 

• Performance Improvement (Hard Skills)
• In-Service Participation (Soft Skills)
• Skilled Nursing Care (Hard Skills)
• Care Plan Development (Hard Skills)
• Symptom Management (Hard Skills)
• Plan Verification (Hard Skills)
• Care Integration (Hard Skills)
• Aide Supervision (Soft Skills)

Job Summary: 

• Provides medical care, palliates, and manages terminal illness in compliance with the state Nurse Practice Act.
• Completes history and physical examinations by evaluating the patient’s medical condition and health history.
• Manages health conditions and terminal illnesses.
• Completes the hospice face-to-face visit requirements.
• Provides clinical information to the hospice medical director for interpretation for eligibility for hospice recertification.
• Makes recommendations to the hospice medical director regarding patient eligibility for certification and recertification for hospice care.
• Reviews clinical information, coordinates, and oversees patient care in consultation with the hospice interdisciplinary team and other healthcare practitioners.
• Reviews and develops protocols for treatment and proposes options for interventions.

Skills on Resume: 

• Medical Care (Hard Skills)
• Physical Assessment (Hard Skills)
• Condition Management (Hard Skills)
• Face-to-Face Visits (Hard Skills)
• Clinical Reporting (Hard Skills)
• Eligibility Evaluation (Hard Skills)
• Care Coordination (Hard Skills)
• Protocol Development (Hard Skills)

Job Summary: 

• Communicates and collaborates with the interdisciplinary group to create, review, and revise the patient’s plan of care.
• Consults with the patient’s attending physician, the hospice medical director, and other healthcare practitioners regarding the patient’s eligibility for hospice care.
• Communicates with other community health practitioners to coordinate the plan of care.
• Attends and participates in hospice interdisciplinary group meetings
• Educates & counsels patients, families, and/or caregivers as to preventative care, medical problems, psychological problems, and spiritual problems.
• Provides and maintains a safe environment for the patient.
• Establishes, builds, and nurtures relationships with staff and community referral sources to facilitate program growth.
• Honoring the patient and family with compassion and care at this pivotal time

Skills on Resume: 

• Team Collaboration (Soft Skills)
• Physician Consultation (Hard Skills)
• Care Coordination (Hard Skills)
• Meeting Participation (Soft Skills)
• Patient Education (Soft Skills)
• Safety Maintenance (Hard Skills)
• Relationship Building (Soft Skills)
• Compassionate Care (Soft Skills)

Job Summary: 

• Makes visits to the homes of patients requiring home health nursing services and assumes responsibility for an ongoing interdisciplinary assessment of the patient.
• Performs initial and comprehensive assessments on all patients according to agency policies and procedures.
• Performs nursing assessment at each visit according to agency policies and procedures.
• Delivers quality care and completes clear, concise, and accurate clinical documentation of care provision by home health conditions of participation (CoPs), various payer home health coverage criteria, accreditation standards, professional standards for discipline/credential, and the home health plan of care.
• Provides patient, caregiver, and family counseling and education as indicated in the plan of care.
• Develops and continually updates a plan of care that specifies the care and services required to meet patient-specific needs.
• Develops and updates the patient’s discharge plan on every visit, ensuring that patient and caregiver education and training facilitate timely discharge.
• Assesses the need for plan of care updates and every visit and includes the patient and family in care planning decisions.
• Maintains accurate and timely documentation of clinical records and time/travel entries

Skills on Resume:  

• Home Visits (Hard Skills)
• Patient Assessment (Hard Skills)
• Quality Documentation (Hard Skills)
• Care Counseling (Soft Skills)
• Care Planning (Hard Skills)
• Discharge Planning (Hard Skills)
• Family Inclusion (Soft Skills)
• Record Maintenance (Hard Skills)

Job Summary: 

• Coordinate patient/family care to support terminally ill patients and families in a home, skilled nursing facility, or residential care facility.
• Assess home care needs, being aware of the physical, emotional, and spiritual aspects as well as gather data on social, economic, and cultural factors which may influence health, well-being and quality of life
• Prepare clinical notes and other required documentation within the required time frames.
• Consult with primary care provider and other health professionals 
• Develop and maintain rapport with patients and families and work well with an interdisciplinary team
• Identify patient/family goals and evaluate the patient’s response to care.
• Involves patient/family in creation of plan of care and provides care according to plan of care.
• Provide case management, advocacy, and resource linkage

Skills on Resume: 

• Care Coordination (Hard Skills)
• Needs Assessment (Hard Skills)
• Clinical Documentation (Hard Skills)
• Provider Consultation (Hard Skills)
• Team Collaboration (Soft Skills)
• Goal Evaluation (Hard Skills)
• Family Inclusion (Soft Skills)
• Case Management (Hard Skills)

Job Summary: 

• Assess home care needs, being aware of the physical, emotional, and spiritual aspects, and gather data on social, economic, and cultural factors which may influence health, well-being and quality of life.
• Assist patients, family members, or other clients with concern and empathy
• Respect confidentiality and privacy and communicate courteously and respectfully.
• Provide direct care to patients as prescribed in the Interdisciplinary Plan of Care in order to maintain the highest level of comfort and quality of life and assume primary responsibility for case management.
• Evaluate and perform ongoing assessment and revise the initial written plan of care with Interdisciplinary collaboration weekly or as the needs and conditions of the patient/family change.
• Authorize, coordinate and supervise care, as prescribed in the Interdisciplinary Plan of Care, with contracted vendors in order to meet the needs of the patient
• Attend and participate in weekly Interdisciplinary Team Meetings
• Document accurate and ongoing assessment of patient status via a variety of mediums of communication (verbal, written, email, computer documents and databases). 

Skills on Resume: 

• Patient Assessment (Hard Skills)
• Empathy (Soft Skills)
• Confidentiality (Soft Skills)
• Direct Care (Hard Skills)
• Care Plan Review (Hard Skills)
• Care Coordination (Hard Skills)
• Team Collaboration (Soft Skills)
• Documentation (Hard Skills)

Job Summary: 

• Document patient care reflecting nursing interventions, patient response to care, patient needs, problems, capabilities, limitations, and progress toward goals. 
• Documentation includes evidence of appropriate patient/significant other teaching, and the understanding of these instructions is noted in the medical record. 
• Maintain up-to-date charts and records on patient care and regular communication with the patient’s physician regarding changes in the patient’s plan of care.
• Coordinate community resources and other agency disciplines participating in patient care.
• Supervise and maintain ongoing effective communication with other personnel involved with patient care, involved formal and informal team meetings.
• Perform patient intakes and information visits, including explanation of the home health/hospice benefit/Medicare, complete physical assessment, completion of all pertinent paperwork, and communication of new patient status to the IDT members.
• Establish HHA plan of care as well as indirectly and directly supervising the plan of care per regulations.
• Elevating Necessary Matters to the Attention of the Patient Care Manager

Skills on Resume: 

• Patient Documentation (Hard Skills)
• Teaching Documentation (Hard Skills)
• Chart Maintenance (Hard Skills)
• Resource Coordination (Hard Skills)
• Team Communication (Soft Skills)
• Patient Intake (Hard Skills)
• Care Plan Supervision (Hard Skills)
• Issue Escalation (Soft Skills)

Job Summary: 

• Ensures the provision of quality nursing service by assigned staff.
• Provides ongoing direction, guidance and evaluation of Hospice Nurses and ensures that professional standards are maintained.
• Assesses requests for hospice service and initiates measures to provide for meeting identified service needs.
• Maintains clinical skills and professional nursing competency.
• Maintains, improves, and applies knowledge of principles, practices, and techniques of management.
• Assumes responsibility for professional growth and continuing education.
• Establishes and maintains effective working relationships with staff, peers, supervisors and community agencies.
• Analyzes the caseload to ensure provision of appropriate and adequate service and to determine staffing needs.
• Provides administrative back-up for evening and weekend staff.
• Directs and guides staff in their professional development in performing job responsibilities.

Skills on Resume: 

• Staff Management (Hard Skills)
• Performance Evaluation (Hard Skills)
• Service Assessment (Hard Skills)
• Clinical Competency (Hard Skills)
• Management Knowledge (Hard Skills)
• Professional Development (Soft Skills)
• Relationship Building (Soft Skills)
• Caseload Analysis (Hard Skills)

Job Summary: 

• Utilizes the nursing process and holistic approach to appropriately case manage and coordinate patient/family care.
• Assesses patient and family unit’s physical (with particular attention to pain and other distressing symptoms of dying), psychosocial, dietary, environmental, spiritual and financial needs relative to Hospice Care.
• Develops, plans and coordinates an individualized patient/family plan of care with the input of the Interdisciplinary Hospice Team and attending physician..
• Implements the Plan of Care (POC), which includes patient/family support, education and initial bereavement plan.
• Evaluates the effectiveness or outcomes of POC, notifies the physician of a change in the client’s status, and coordinates any adjustments of the POC.
• Maintains a responsible pattern of work attendance and promptness.
• Schedules patients’ visits appropriately, given patient /family needs, and notifies patients/families in advance of visits to minimize absent visits.
• Participates as an active member of the Hospice Interdisciplinary Team.
• Understand “who” (internal & external) the customers are.
• Provides written, oral, and non-verbal communication to all customers that is prompt, clear, respectful, helpful, and effective.
• Acts as an organizational system liaison for the client and family unit in communication/coordination with the health care team.

Skills on Resume: 

• Case Management (Hard Skills)
• Needs Assessment (Hard Skills)
• Care Planning (Hard Skills)
• Plan Implementation (Hard Skills)
• Outcome Evaluation (Hard Skills)
• Attendance Reliability (Soft Skills)
• Scheduling Coordination (Hard Skills)
• Team Participation (Soft Skills)

Job Summary: 

• Provides nursing coverage for Home Care and Hospice patients, covering all visits, related scheduled, and unanticipated and triaging of all calls.
• Documents all calls and visits same day as the visit, per agency standard.
• Ensure there are physician orders before delivering services, and OASIS accuracy
• Complete a comprehensive assessment including physical, psycho/social, and spiritual aspects of the patient/family.
• Perform services/treatments for the patient as indicated in the plan of care based on physician orders.
• Develop and implement a plan of care (within 48 hours for Hospice patients) for the patient. 
• Analyze the plan on going and develop interventions/changes 
• Review and complete a comprehensive assessment within 5 days of the notice of election for Hospice patients.
• Effectively integrate educational, medical, social, and psychological factors when evaluating progress towards attainment of goals and outcomes.
• Complies with medical, regulatory, educational, and records management requirements (e.g., insurance authorization, consents, physician's referral, documentation) and maintains patient confidentiality by HIPAA guidelines and patient rights and responsibilities.

Skills on Resume: 

• Nursing Coverage (Hard Skills)
• Call Documentation (Hard Skills)
• Physician Orders Compliance (Hard Skills)
• Comprehensive Assessment (Hard Skills)
• Plan Implementation (Hard Skills)
• Plan Analysis (Hard Skills)
• Progress Evaluation (Hard Skills)
• Regulatory Compliance (Hard Skills)

Job Summary: 

• Communicates with all physicians and other health care practitioners involved in the patient's plan of care to exchange, discuss, and evaluate patient information for planning, modifying, and coordinating an appropriate treatment plan and goals.
• Assess for patient, caregiver, and/or representative and family counseling needs and make appropriate referrals. 
• Provide patient caregiver, and/or representative education, including diagnosis, interventions, community resources, medications, a safe and therapeutic environment, coping strategies, and discharge etc.
• Document assessment, interventions, medication reconciliation, and discharge planning in appropriate clinical notes and plan of care.
• Completes documentation same day as visit, per agency standard. 
• Participates in the agency's quality assessment process improvement (QAPI) program to improve health outcomes, patient safety, and quality of care.
• Meets agency obligations for scheduling, on-call, weekend, and evening coverage, and expected productivity standards. 
• Meets agency obligations for holiday coverage, weekend coverage, and on-call shifts. 
• Complies with Agency standards for productivity, patient and staff schedules, and attendance at meetings.
• Enhances professional growth and development through participation in educational programs, current literature, community-based and home health agency services, meetings, workshops, and provides training to staff, agency, and community groups. 
• Complies with professional licensure standards and code of ethics.

Skills on Resume: 

• Physician Communication (Hard Skills)
• Counseling Referral (Hard Skills)
• Patient Education (Hard Skills)
• Clinical Documentation (Hard Skills)
• Quality Improvement (Hard Skills)
• Scheduling Compliance (Hard Skills)
• Attendance Reliability (Soft Skills)
• Professional Development (Soft Skills)

Job Summary: 

• Screen and process inquiries for admission to Hospice by the Bay's total care category.
• Determine the patient's eligibility for hospice care.
• Make telephone contact and/or assessment visits with potential hospice patients to provide information on agency services and/or assess patients' status.
• Assist with the implementation and coordination of services required for the discharge of patients from hospitals into the agency's program of care.
• Maintain current documentation in the computerized clinical documentation system according to agency policies and procedures and applicable laws and regulations.
• Assume initial responsibility for assessing patient/family needs and consulting with the attending physician and other hospice staff members.
• Admit patients, obtain informed consent(s) for service, inform patient/family of rights and responsibilities, develop plan of care and complete related documentation in accordance with agency policies and procedures.
• Provide initial instructions to primary caregivers, volunteers and employed caregivers regarding the plan of care.
• Inform the Team Leader and TDT of unusual or potentially problematic patient/family issues.
• Attend the TDT conference to relay informa­tion to the TDT about new patients and to ensure continuity of the agency's patient care service as indicated.
• Facilitate the transition of the patient/family to the Patient Care Team promptly.
• Manage patient/family care plan and accompanying services between the time of admission and transition to the Nurse Case Manager

Skills on Resume: 

• Admission Screening (Hard Skills)
• Eligibility Determination (Hard Skills)
• Patient Assessment (Hard Skills)
• Discharge Coordination (Hard Skills)
• Clinical Documentation (Hard Skills)
• Consent Management (Hard Skills)
• Caregiver Instruction (Soft Skills)
• Team Communication (Soft Skills)

Job Summary: 

• Providing physical and emotional support to patients and their families.
• Assuming primary responsibility for a patient and family caseload, including assessments, planning, implementing and evaluating phases of the nursing process.
• Administering and instructing the administration of medication.
• Initiating communication with physicians, other hospice team members and other agencies to coordinate care.
• Maintaining current patient records and progress notes.
• Supervising LPNs and Hospice Aides, and document delivery of care 
• Professional Management of the patient and family
• Communication with Medical Professionals, the Hospice Team, and others 

Maintaining Accurate, Up-to-Date Records

Skills on Resume: 

• Patient Support (Soft Skills)
• Case Management (Hard Skills)
• Medication Administration (Hard Skills)
• Care Coordination (Soft Skills)
• Record Keeping (Hard Skills)
• Staff Supervision (Hard Skills)
• Professional Management (Soft Skills)
• Medical Communication (Soft Skills)

Job Summary: 

• Prepare and adjust patient care plans 
• Monitor patient vital signs and comfort levels
• Assist in administering medication
• Alert physicians about changes in patients' conditions
• Provide patient care information, end-of-life education, and emotional support to loved ones and primary caregivers
• Maintain and update patient records, medical charts, and patient files
• Develops and maintains a therapeutic relationship through the health care continuum
• Responsible for documentation and communication of care, medication, and observations made during care of the patient to track responsiveness and health of the patient.
• Responsible for providing appropriate patient/family education to help patients/families achieve a pain-free and comfortable status.
• Facilitates the patient and family's right to receive quality, cost-effective care.

Skills on Resume: 

• Care Plan Preparation (Hard Skills)
• Vital Signs Monitoring (Hard Skills)
• Medication Assistance (Hard Skills)
• Physician Notification (Hard Skills)
• Patient Education (Soft Skills)
• Record Maintenance (Hard Skills)
• Therapeutic Relationship (Soft Skills)
• Care Documentation (Hard Skills)

Job Summary: 

• Provides nursing care with special emphasis on control of pain and other symptoms for the hospice patient.
• Assess the physical and psychological status of the patient.
• Identifies problems/needs of the patient and of the caregiver, making recommendations for pain management and comfort/symptom management.
• Coordinate care with other disciplines 
• Responds to calls promptly when received from the answering service. 
• Communicates information regarding the patient's plan of care with other hospice staff members 
• Responsibilities will include assessing, planning, implementing, and evaluating patient-centred specialist palliative nursing care within a friendly team
• Ensuring that all clinical practice is of the highest standard, following clinical policies, procedures, and guidelines at all times.               
• Provide mentorship and teaching to students and new members of the team.

Skills on Resume: 

• Pain Management (Hard Skills)
• Patient Assessment (Hard Skills)
• Problem Identification (Hard Skills)
• Care Coordination (Soft Skills)
• Call Responsiveness (Soft Skills)
• Plan Communication (Soft Skills)
• Clinical Practice Standards (Hard Skills)
• Mentorship (Soft Skills)

Job Summary: 

• Providing skilled nursing patient care under the supervision of a registered nurse.
• Follows the plan of care and follows the comprehensive assessment
• Provides accurate and timely documentation of patient services to reflect the plan of care
• Administers medication and treatments as ordered by the physician
• Assess and provide patient and family/caregiver education and information pertinent to diagnosis and self-plan of care.
• Reports the ongoing changes about the patient to the interdisciplinary team, including, registered nurse, hospice aid, and DOPCS.
• Adhere to company policies and procedures and regulatory compliance requirements, and directives.
• Timely documentation of all after-hours calls and visits, including problem and intervention.

Skills on Resume: 

• Nursing Care (Hard Skills)
• Plan Adherence (Hard Skills)
• Documentation (Hard Skills)
• Medication Administration (Hard Skills)
• Patient Education (Soft Skills)
• Team Reporting (Soft Skills)
• Regulatory Compliance (Hard Skills)
• After-Hours Documentation (Hard Skills)