Admissions and Transitional Care Nurse

Hope Hospice – Loving Professionals with a Shared Vision to Serve We are recognized as a Top Workplace and have been named Best of New Braunfels' Best Hospice for 14 years and Best Thrift Shop for 10 years.Since 1984, Hope Hospice has assisted over 25,000 patients and their families with hospice services. As a non-profit, community-owned organization, we believe in providing exceptional, compassionate care, focusing on the quality of life for anyone who qualifies for service, regardless of their ability to pay. We love our employees just as much as we love our patients. That’s why we’ve put together a generous benefits package that includes: Health Medical, Dental, and Vision - paid 100% for employee only; competitive plan cost for dependents Health Savings Account with matching employer contributions of $100 per month Company-paid Long-Term Disability, Life and Accidental Death/Dismemberment, and an Employee Assistance Program paid for by Hope Hospice Additional Life and Accidentand Critical Illness, FSA Dependent Care, Short-Term Disability, and other voluntary benefits are available Time Off Vacation - up to 4 weeks per year Sick - up to 2 weeks per year Personal Days (3) Paid Holidays (8) 403(b) retirement savings plan with company match up to 5% Tuition Assistance Opportunities for professional career development and growth Continuing education opportunities If you require assistance or accommodation completing our application process, please contact the Human Resources department at View phone number on click.appcast.io, Monday through Friday, 8:0 am to 5:0 p.m. We are an equal-opportunity employer. Human Resources Department 611 N. Walnut Ave New Braunfels, TX 78130 Email: View email address on click.appcast.io Fax: View phone number on click.appcast.io Position: Admissions and Transitional Care Nurse Location: New Braunfels, TX Job Id: 327 # of Openings: 1 Admissions and Transitional Care Nurse What we offer: Generous paid time off package (4 weeks of vacation time, 2 weeks of sick time, 3 personal days, and 8 paid holidays) Medical, Dental, and Vision - paid 100% for employee only; competitive plan cost for dependents Health Savings Account (HSA) with matching employer contributions of up to $100 per month Company paid Long-Term Disability, Life and Accidental/Dismemberment, and Employee Assistance Programs Additional Life and Accident and Critical Illness, FSA/Dependent Care, Short-Term Disability, and other voluntary benefits are available 403(B) Retirement Savings Plan with company match up to 5% End of year gift Tuition Assistance Job Summary Receives referrals, performs initial assessments, coordinates establishment of the plan of care, and collaborates with the interdisciplinary team. This position works Saturday, Sunday, and Monday. On Monday, the nurse assumes responsibility for General Inpatient care patients admitted over the weekend, including assessment, symptom-management coordination, physician collaboration, and discharge planning. After all GIP patients have been seen and their immediate needs addressed, the nurse completes any remaining admissions as assigned. Job Summary Receives referrals, performs initial assessments, coordinates establishment of the plan of care, and collaborates with the interdisciplinary team. This position works Saturday, Sunday, and Monday. On Monday, the nurse assumes responsibility for General Inpatient care patients admitted over the weekend, including assessment, symptom-management coordination, physician collaboration, and discharge planning. After all GIP patients have been seen and their immediate needs addressed, the nurse completes any remaining admissions as assigned. Work Schedule Regular workdays are Saturday, Sunday, and Monday / 12 hour shifts Provides admission coverage on Saturday and Sunday based on referrals, patient needs, and operational priorities. On Monday, gives first priority to all GIP patients admitted during the weekend. Outstanding admissions are completed after required GIP visits and care coordination are finished. Maintains flexibility in daily scheduling to respond to patient acuity, referral volume, travel requirements, and changing organizational needs. Qualifications Graduate of an approved school of nursing, preferably with a Bachelor of Science in Nursing degree. Current license to practice professional nursing in the State of Texas. Reliable means of transportation, a valid Texas driver's license, and automobile insurance. One or more years of clinical nursing experience. Strong assessment skills and experience with an interdisciplinary approach are preferred. One year of experience as a case manager for Hope Hospice is preferred. Understanding of family dynamics, conflict resolution, and principles of adult learning. Pain and symptom management skills, crisis intervention expertise, and patient and family teaching and counseling skills. Professional appearance, behavior, attitude, and integrity. Ability to work independently and interact effectively with patients, families, facility staff, physicians, and coworkers. Demonstrated flexibility, self-motivation, dependability, and commitment to teamwork. Effective verbal and written communication skills. Working knowledge of computers and electronic medical records. Critical-thinking and problem-solving skills, including the ability to make decisions, set priorities, and maintain timely, accurate, and orderly records. Duties and Responsibilities Admissions and Initial Assessment Process Visits the patient to assess and determine compliance with hospice admission criteria and performs a comprehensive initial nursing assessment. Communicates findings to the Medical Director and attending physician to complete the start of care and begins coordination of services. Educates the patient and family about hospice services, assesses needs and preferences, and initiates referrals for needed and desired services. Ensures the initial plan of care is based on a comprehensive assessment of physical, psychosocial, safety, age-related, spiritual, financial, environmental, and cultural needs, resources, and preferences. Ensures the initial assessment includes pain and symptom assessment, history of interventions and responses, and evaluation of the patient and caregiver's knowledge and learning needs. Reviews the plan of care with the assigned nurse, chaplain, social worker, hospice aide, and other appropriate team members. Completes all electronic communication and documentation accurately, completely, and within required timeframes in accordance with policy and applicable rules and regulations. Effective and professional collaboration, coordination, and relationship management with referral sources, facility/hospital staff. Reviews the weekend handoff and identifies every GIP patient admitted on Saturday or Sunday before beginning Monday field visits. Completes an in-person nursing visit for each weekend GIP admission and evaluates continued eligibility for the GIP level of care, current symptom burden, response to interventions, medication effectiveness, and changes in condition. Provides active clinical management of assigned GIP patients until responsibility is formally transitioned, including timely follow-up on symptoms, orders, and changes in the plan of care. Collaborates with the hospice physician and attending physician regarding symptom management, continued GIP eligibility, medication or treatment changes, and readiness to transition to a lower level of care. Collaborates with the social worker, hospital or facility care-management staff, patient, and family to begin or advance discharge planning as soon as clinically appropriate. Identifies the anticipated discharge setting, caregiver availability, equipment, medication, transportation, education, and other services needed for a safe transition. Keeps the patient and family informed of the plan of care, the purpose and daily review requirements of GIP care, and expected next steps in discharge planning. Communicates the patient's status, barriers, orders, and discharge plan to the interdisciplinary team and appropriate clinical leadership. Documents the visit, assessment, physician communication, interventions, patient response, continued GIP eligibility, and discharge-planning activity accurately and timely in the electronic medical record. After all GIP patients have been assessed and their immediate clinical and discharge-planning needs have been addressed, completes any admissions that remain outstanding or are assigned for Monday. Interdisciplinary Team Coordinates development of the initial plan of care with interdisciplinary team members. Presents new patient admissions at the interdisciplinary team meeting as assigned. Provides clear handoff communication to the assigned case manager and other team members to support continuity of care. Referrals and Education Creates opportunities for new referrals while working in the community. Presents Hope Hospice programs and services to others in the community as a member of the agency-wide marketing team. General Responsibilities Supports the philosophy and objectives of Hope Hospice. Maintains professional competency and licensure. Stays current with accreditation standards and governmental regulations affecting hospice care. Works effectively both independently and within the interdisciplinary team structure. Documents effectively and timely to support optimal communication, reimbursement, accreditation, and compliance. Promotes a team approach through cooperation, mutual respect, flexibility, and dependability. Remains open, sensitive, flexible, and ecumenical, using good judgment and sound reasoning. Participates in appropriate meetings and activities, including performance improvement. Demonstrates responsible stewardship of organizational resources, including self-care. Seeks personal growth and contributes to an atmosphere of excellence, respect, and caring. Reads relevant materials and attends in-services, seminars, or conventions for professional growth. Assists with orientation of new employees or volunteers as assigned. Performs other duties as assigned. Working Conditions This position requires operation of a motor vehicle to travel to and from assignments in patient homes, hospitals, nursing facilities, and other care settings. Duties may include climbing stairs and negotiating ramps of varying sizes, types, and conditions; navigating outdoor and indoor environmental hazards; and working under a wide variety of conditions in patients' places of residence. The nurse must have sufficient manual dexterity to manage IV procedures, specimens, equipment, and medications. The position may require repeated lifting, carrying, pushing, or pulling of more than 50 pounds and carrying agency-provided electronic equipment used to complete the electronic medical record. The nurse may be exposed to blood, body fluids, infectious diseases, and other occupational hazards associated with providing direct patient care. Please note this job description has been designated to include the general nature and level of work performed by employees in this position. It is not designed to contact or to be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of the employee assigned to this job. Duties, responsibilities, and activities may change at any time with or without notice. Hope Hospice is an equal opportunity employer regardless of gender, pregnancy, sexual orientation, age, race, national origin, religion, color, veteran status, disability, genetic information, or any other category protected by federal, state, or local laws. #J-18808-Ljbffr Hope Hospice