Hospice Care Planner

Works with staff from the MJHS Institute and MJHS Hospice and Palliative Care to implement projects that identify and assess medically ill patients in specific venues and provide direct services that increase the frequency and quality of goal setting discussions, advance care planning, and hospice eligibility review and enrollment. Implements protocols developed for the project and obtains and documents data necessary to evaluate the project. When appropriate, manages and facilitates the transition of patients to hospice in accordance with applicable law, regulations and agency policies and procedures. May provide clinical support, leadership and oversight for growth and development of community and facility-based hospice programs. Provides education to professionals at the site of the project, as necessary to advance its goals and improve the quality of care. Qualif Responsibility: Responsible for programmatic implementation of projects intended to promote goal setting, advance care planning and hospice eligibility review and enrollment in populations with advanced illness. Performance Standards: • Effectively collaborates with senior management to ensure that project implementation proceeds in alignment with goals and objectives. • Implements protocols to identify patients appropriate for project. • Communicates with physicians and other members of treatment team and collaborates with them in the implementation of the project. • When patient is identified, determines eligibility for the project. Communicates with patients and families, and facilitates or engages in goal setting discussions, including advance care planning. • Performs hospice eligibility review, including discussions as appropriate with the patient’s physician and the hospice physician. • When appropriate, engages in discussions with patients and families about hospice eligibility and enrollment. • Assists with obtaining the Election of Benefits and in the completion of hospice admissions. • Ensures timely and accurate implementation of procedures for distribution, tracking, return, turnover, and quality control of telehealth devices. • Creates and implements patient/family educational materials to support the use of telehealth. • Tracks and supports programmatic efforts to ensure that patients and families are appropriately identified and evaluated for telehealth, and that device triaging is appropriately performed. • Assists and problem-solves so that timely and accurate implementation of specific telehealthenabled interventions occur, as determined by clinical need and directed by senior management. Responsibility Maintains Effective Communication within Hospice & Palliative Care & Referral Sources. Performance Standards: • Offers clear direction regarding how to be reached, and when contacted, gives a positive response to requests for information and patient assessments. • Makes every attempt to respond same day to requests for patient assessment and family meetings. • Responds to referral sources phone, beeper and e-mail communication in a timely manner. • Attends and participates in the regular Staff Meetings • Communicates consistently with MJHS Hospice Access Center Staff regarding new referrals, volume, issues and assistance needed. 3. Responsibility Gathers all information required by the agency to initiate a hospice referral, when appropri • Licensed with current Registration to practice as Registered Professional Nurse in NYS is required. • Bachelor's Degree preferred. • Must have a minimum of two years experience in Hospice nursing with proficiency in physical assessment and interviewing skills. • Must be client-service focused with excellent written and verbal communication skills. • Advanced critical thinking and problem solving skills, plus the ability to work independently is essential. • Bilingual Spanish/English is required in some locations.