RN Hospital Liaison

About the role

Make a lasting impact with Agrace Join Agrace, a nationally recognized nonprofit leader in hospice and palliative care. If you are a skilled RN who values meaningful, patient-centered care, this is your opportunity to make a difference!

Responsibilities

• Act as Liaison between Agrace, Hospital Staff and Physician, and Patient and Family
• Serve as a resource and consultant for hospital/clinic staff, physicians, nurses, social workers, chaplains about pain, symptom management, end-of-life issues, hospice/palliative care philosophies and services.
• Serve as a consultant to patients and families about end-of-life issues and Agrace philosophies and services.
• Actively pursue relationships and develop partnerships with all referral sources to promote the benefits of Agrace services.
• Evaluate Patient for Agrace Hospice and Palliative Programs
  • Review medical records to identify hospice and palliative care services eligibility, physician orders, and to verify diagnosis.
  • Identify if patient meets admission criteria in collaboration with primary care, specialty, and Agrace physicians.
  • Collaborate with the Interdisciplinary Team (IDT) and primary care provider to create a Hospice Eligibility Summary (HES) for determination of hospice eligibility.
  • Identify if patient meets admission criteria by assessing patient’s physical, pain, psychosocial, emotional, spiritual, environmental, fall, medication safety, and educational needs.
  • Collect data from the patient, family, significant other and other health care professionals about immediate goals and needs.
  • Collaborate with the Admission’s Certification Nurse or Clinical Team Manager (CTM) regarding all patients deemed ineligible for hospice services.
• Plan of Care (POC) and Discharge Planning
  • Formulate and implement individualized POC and/or Discharge Plan in collaboration with hospital staff, patient, nursing facility, and family.
  • The POC will include goals, symptom management, interventions, education, coroner involvement, etc.
  • Identify potential care challenges and document interventions in the POC to minimize, manage, or resolve the concern.