HH Comfort Care RN

GENERAL DESCRIPTION:
Under the direct supervision of the HH Nursing Supervisor / HH Administrator, the HH Comfort Care Nurse, RN is responsible for the delivery of direct participant care provided to Bienvivir Comfort Care participants at their place of residence and in the clinic. The comfort care nurse provides skilled nursing care with a focus on symptom management, quality of life, and alignment with participant goals of care, while ensuring compliance with PACE, CMS and Texas Health and Human Services Commission (HHSC) regulatory requirements. The Comfort Care Nurse is responsible for the daily coordination of participant care in the following areas: participant assessments, care planning and coordination, symptom and disease management, health education and support, prevention and maintenance, documentation and compliance, communication and team collaboration.

RESPONSIBILITIES: 
Direct Participant Care
1. Performs skilled nursing visits in the participants’ private residence, clinic, assisted living facilities, and other approved locations. 
2. Provides comfort-focused nursing interventions aimed at relieving pain, dyspnea, anxiety, nausea, agitation, and other distressing symptoms. 
3. Administers medications and treatments per provider orders, with particular attention to high-risk medications and comfort medications. 
4. Evaluates effectiveness of interventions and modifies care delivery in collaboration with the interdisciplinary team (IDT).
Nursing Assessments
1. Complete initial, ongoing and as needed required nursing assessments of individual participants, including evaluation of medication compliance, change of condition, symptom burden and functional status. 
2. Routine visits will be completed on the participants scheduled Interval Assessment date, in accordance with the CMS guidelines.
3. Initial start- of- care in-home assessments will be completed within 72 hours of the participants’ enrollment into the comfort care program. Consequently, monthly assessments will be completed in compliance with Texas Health and Human Services Commission (HHSC) requirements.
4. Complete reassessments promptly upon the request of participant/ or designated representative, with urgency determined by the severity of the participant’s condition.
Care planning and Coordination
1. Develops, implements, and updates individualized comfort care plans in collaboration with the participants, caregivers, providers, and IDT. 
2. Ensures care plans are consistent with participant goals of care, advanced directives, that meet the standards mandated by PACE, HHSC and nursing practice. 
3. Coordinates daily care needs across disciplines, including providers, pharmacy, social services, rehabilitation, and any other discipline, as appropriate.
4. Facilitates transitions of care and supports continuity across settings. 
Symptom Management and Disease Management
1. Implements evidence-based comfort care interventions for participants with advanced illness and chronic disease. 
2. Monitors disease progression and symptom trends through ongoing assessment, including weekly telephone follow-ups with the participant and/or caregiver, to proactively adjust care strategies as needed.
3. Supports the management of chronic conditions within a comfort-focused plan of care, prioritizing symptom relief while minimizing unnecessary or burdensome interventions. 
4. Observes participants for changes in condition and promptly reports findings to the Comfort Care provider and designated clinical leadership.
5. Collaborates closely with providers to recommend medication adjustments, alternative therapies, and supportive measures based on participant response and goals of care. 
6. Obtains and implements provider orders for changes to the medical plan of treatment in response to changes in the participant’s condition.
7. Works collaboratively with providers in the daily management of participant care, including monitoring ill participants, assisting with procedures as indicated, and ensuring timely implementation of prescribed medications and treatments. 
8. All assessments, observations, interventions, communications, and participant responses are documented accurately and timely in the medical record.
Health Education and Support
1. Provides ongoing education to participants and their caregivers regarding disease processes and anticipated progression. 
2. Educates on the purpose of medications—including end-of-life and comfort-focused medications—the proper administration of these medications, and potential side effects.
3. Instructs participants and caregivers on symptom monitoring, comfort measures, and safety practices to support effective self-management and promote participant well-being.
4. Reinforces education of the Comfort Care Program in a culturally sensitive and participant-centered manner. 
5. Supports participants and caregivers emotionally, addressing concerns related to comfort, coping, and care expectations.
Prevention and Maintenance
1. Implement strategies to prevent hospitalizations and Emergency Room visits. 
2. Prevents complications such as skin breakdown, falls, medication errors, and unmanaged symptoms. 
3. Monitors and promotes skin integrity, nutrition, hydration, and mobility within the participant’s tolerance and goals.
4. Identifies risk factors and initiates preventive interventions aligned with comfort care principles and goals.
Documentation and Compliance
1. Documents all assessments, interventions, education, and participant responses accurately and timely in the medical record as required by departmental policies and procedures. Ensures documentation reflects skilled nursing services, medical necessity, and alignment with the established plan of care. 
2. Maintains compliance with PACE regulations, CMS, state nursing practice standards, and agency policies. 
3. Audits Pharmacy med orders and medication expiration dates, to include narcotics for Comfort Care participants during routine monthly visits and as needed. 
4. Review and coordinate all consultations and follow-up visits to include procedures and any needed medications. 
5. Responsible for reviewing Lab results and providing the provider with results.
6. Assures all Level II reporting guidelines/requirements are reported.
Communication and Team Collaboration
1. Interact and work with caregivers/families and/or designated representatives to coordinate participant care, and respond to participant and caregiver phone calls, to include providing education and counseling. 
2. Coordinates with participant, family, caregiver and staff or contacted providers to ensure 24-hour service delivery.
3. Maintains ongoing communication with the Home Health Nursing Supervisor and/or Administrator regarding participant status and care delivery; problem solve, if necessary. 
4. Assists and participates in daily department huddles.
5. Participate in IDT morning meetings in person, if applicable.
6. Participates in IDT discussions, medical updates where comfort care is anticipated as a goal of care. 
7. Participate in case conferences and care planning meetings. 
8. Interact and work closely with IDT, medication and treatment nurses and personal care workers to coordinate comprehensive participant care.
9. Escalates clinical concerns, changes in condition, or safety issues promptly. 
10. Serves as a clinical resource, advocate and liaison for comfort care participants. 
11. Coordinate hospital and Nursing Home admissions, discharges, and transfers for Comfort Care participants. 
Other Responsibilities
1. Will assist with the holiday on-call rotation, will be available for telephone triages withparticipants, addressing family and caregiver concerns and conduct as needed at-home visits, if warranted. 
2. In the absence of the Home Health Nursing Supervisor (RN), may perform delegated charge responsibilities, including coordination of Comfort Care conferences with the operational social workers and management of the Comfort Care NP schedule.
3. Attend monthly and as needed Comfort Care/ HH meetings and staff in-services. 
4. Complete all assigned mandatory in-person or online training.
5. Participates in audits, quality improvement activities, and performance monitoring as assigned. 
6. If appropriate, participates in State and national organizations, meetings, seminars, workshops, and activities relating to the health profession and health care services. 
7. Protects participant confidentiality in accordance with HIPAA
8. Performs other duties as assigned by Home Health Nursing Supervisor, RN or HH Administrator. 

QUALIFICATIONS / REQUIREMENTS:
1. A graduate of an accredited nursing program with a license to practice in the state of Texas as a Registered Nurse. 
2. One year of experience with a frail or elderly population preferred. 
3. Have at least one year experience as an RN obtained within the last 36 months.
4. Over 2 years’ experience in Home Health and/ or PACE setting preferred. 

KNOWLEDGE, SKILLS, AND ABILITIES: 
1. An individual with a strong knowledge base and keen understanding and appreciation of the elderly. 
2. Must be able to function in a practice environment with minimal direct supervision, accepting personal responsibility for maintaining a professional relationship with Bienvivir’s participants and their families. 
3. Have effective telephone and interpersonal communication skills. 
4. Must have an automobile, valid driver’s license, and current insurance. 
5. Bilingual (English / Spanish). 
6. Computer skills.