Transitional Care Nurse

Description

Longleaf Hospice and Palliative Care is locally owned with offices located in Atlanta, Covington and Roswell, offering end-of-life care to those with life limiting illnesses in the communities we serve. We believe that this very special care is best provided by professionals who live and work in the community they serve. At Longleaf Hospice and Palliative Care, we integrate and address the diverse, seen and unseen needs of patients and their families.

The Transitional Care Nurse provides direct nursing care to patients, care coordination and education to patients, families and staff in general inpatient units in accordance with established policies, procedures, and protocols. This position involves patient assessment, establishment of an individualized plan of care, discharge planning and communication with the hospice physician to meet patient/caregiver needs.

• Completes general inpatient (GIP) admissions, collaborating with the hospital physician and the Hospice physician to assist in determining the patient’s clinical eligibility for hospice care
• Makes visits to assess GIP patients daily while patient is in the hospital
• Participates and plans discharge for those GIP patients that will be transitioned home with hospice, assisting with and completing appropriate paperwork as needed
• Provides education regarding home hospice care and home palliative care to patients that are in the hospital
• Provides education to the hospital staff regarding hospice and palliative care
• Implements and monitors patient care plans
• Monitors, records and communicates patient condition as appropriate
• Serves as primary coordinator of all disciplines for well-coordinated patient care
• Participates in bi-weekly interdisciplinary group (IDG) meetings
• Assesses needs of patient and family and provides education and support based on age, culture and willingness to learn
• Performs home hospice admissions as needed
• Pronounces patients and performs other routine nursing visits when requested
• Participates in Quality Assessment Performance Improvement (QAPI) program and Hospice sponsored in-services
• Performs job duties in accordance with Nurse Practice Act
• Other duties as assigned

• Licensed as a registered nurse in the state of Georgia
• Graduate from an accredited school of nursing
• Minimum of five (5) year’s nursing experience
• Minimum of two (2) years’ experience in hospice/home care preferred
• Certified Hospice and Palliative Care Nurse (CHPN) preferred
• Critical thinking skills and decisive judgment required
• Works under minimal supervision
• Ability to work in a stressful environment required
• Good verbal and written communication and problem-solving skills required
• Responsible valid driver’s license
• Reliable, insured, automobile for making home visits required