Nurse Navigator - Home Health to Hospice Transition

Position Summary: The Nurse Navigator serves as a clinical liaison between Home Health and Hospice services, ensuring patients receive care aligned with their evolving needs. This role focuses on identifying appropriate transitions from home health to hospice, facilitating timely, compassionate conversations, and supporting patients, families, and clinicians through the transition process.

Reports to: Senior Clinical Director

Key Responsibilities:

• Clinical Assessment & Identification
  • Review home health patient population (3000+ census) to identify those who may be appropriate for hospice services based on disease progression, frequent hospitalizations, decline in functional status, or goals of care.

• • Navigate multiple electronic medical record platforms, internal and external, to analyze patient data for identification. Utilize key source reports such as Power BI and SHP to identify high-risk populations.

• • Collaborate with home health clinicians to validate clinical appropriateness for hospice evaluation.
• Care Transition Management
• Coordinate seamless transitions from home health to hospice for eligible patients.
• Ensure timely hospice evaluations and admissions when appropriate.
• Reduce gaps in care, avoid unnecessary hospitalizations, and support continuity.
• Goals of Care Conversations
• Provide education to patients and families regarding disease trajectory, prognosis, and hospice philosophy.
• Support clinicians in having compassionate, compliant goals-of-care discussions.
• Ensuring patient choice and autonomy remain central to all decisions
• Interdisciplinary Collaboration
• Partner with home health nurses, therapists, case managers, physicians, and hospice teams.
• Act as a resource for staff regarding hospice eligibility criteria and benefits.
• Participate in case conferences and high-risk patient reviews.
• Education & Training
• Educate home health staff on hospice criteria, triggers for referral, and regulatory considerations.
• Help build a culture of early identification and appropriate end-of-life planning.
• Performance & Outcomes
• Track and report key metrics such as:
  • Hospice conversion rates from home health
  • Length of stay in hospice
  • Hospitalization rates for end-of-life patients
  • Identify trends and opportunities for earlier intervention.
  • C ompliance & Ethics
• Ensure all practices align with Medicare regulations and ethical standards.
• Maintain clear documentation supporting clinical appropriateness and patient choice.
  Upholds the compliance objectives and policies and procedures of VNA Care and Subsidiaries.
• Performs other related duties of a similar nature and complexity as directed.

Skills and Knowledge:

Qualifications:

• Active Massachusetts RN license / OR will obtain within 3 months
• Minimum 3-5 years of experience in home health, hospice, or palliative care
• Strong understanding of hospice eligibility criteria and Medicare guidelines
• Demonstrated skill in difficult conversations and goals-of-care discussions
• Excellent collaboration and communication skills
• Ability to analyze clinical data and identify trends
• Preferred Qualifications:
• Hospice or palliative care certification (e.g., CHPN)
• Experience in care transitions or case management
• Leadership or program development experience.
• Key Competencies:
• Clinical judgment and critical thinking
• Emotional intelligence and empathy
• Influence without authority
• Data-driven decision-making
• Strong organizational skills