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Skills
Chronic Diseaseunmatched
Consultingunmatched
Cross-Functionalunmatched
Data Qualityunmatched
Documentationunmatched
Durable Medical Equipmentunmatched
Healthcareunmatched
Hospice Careunmatched
Hospitalunmatched
Insuranceunmatched
Medical Officeunmatched
Medicareunmatched
Medicationsunmatched
Nursingunmatched
Pain Managementunmatched
Patient Assessmentunmatched
Patient Careunmatched
Registered Nurse (RN)unmatched
Regulationsunmatched
Social Workunmatched
Statisticsunmatched
Treatment Planunmatched
Description
Description
Evaluates patients referred to the Organization; identifies insurance coverage, plans, and coordinates referrals for hospice care services. Provides General Inpatient (GIP) Start of Care and daily visits for Torrance Memorial Medical Center's GIP patients
Core Competencies
Responds to referrals for hospitalized patients referred for hospice care.
Assesses documentation of care according to specific guidelines thereby promoting consistency in methodology and validity of the resulting data.
Identifies insurance overage of hospice care services.
Consults with physicians, nurses, social workers, discharge planners and other disciplines to assist in establishing a coordinated hospital discharge to hospice services
Demonstrates the ability to conduct thorough, person-centered interviews with patients, families, and caregivers to gather essential information about the home environment, current needs, and non-clinical factors that influence the plan of care.
Completes referral information that includes intake data, essential background information, hospital course, and the plan of care
Maintains liaison relationship with hospital and insurance personnel, providing information and education on hospice services, coverage issues and related areas
Collects and maintains statistical data on all referrals and submits them regularly as required.
Works with other health care clinicians in the development of safe care transition from hospital to community.
Communicates with the appropriate interdisciplinary team members any changes in patient's condition or psychosocial status and coordinates changes in support and services to provide maximum comfort and maintain quality of life.
Complies with all Medicare regulations governing Hospice.
Department Specific Competencies
Accepts referrals from hospitals, physician offices, SNFs and other community referral sources, obtains required orders for services and coordinates infusion products and DME/HME delivery.
Advocates for ethical and holistic care to promote the autonomy, dignity, rights, values and beliefs of those we serve
Allows time for patients, parents or caregiver to ask questions regarding medication, procedures, and follow up care upon discharge or during any intervention.
Collaborates with the multidisciplinary team to coordinate patient care.
Communicates with the patient, family, medical staff and others during the continuum of care
Assesses pain and symptom management, identifies interventions and establishes desired outcomes for care of patients with chronic life limiting illness or at the end of life.
Evaluates effectiveness of plan of care and modifies, as appropriate.
