Clinical Liaison RN

Clinical Liaison RN - PAH

The Clinical Liaison RN - PAH is responsible for modeling the Compassus values of Compassion, Integrity, Excellence, Teamwork, and Innovation and for promoting the Compassus philosophy, using the 6 Pillars of Success as the foundation. S/he is responsible for upholding the Code of Ethical Conduct and for promoting positive working relationships within the company, among all departments, and all external stakeholders. This position represents Compassus Providence JV (JV) Agencies at contracted Providence facilities and requires strong communication and interpersonal skills. The role of the Clinical Liaison RN is to coordinate and arrange home care services between Providence hospital facilities and the JV Agencies for home health and hospice, and other community providers when specifically requested by the patients. The Clinical Liaison RN provides information to ensure a smooth transition for patients and their families following hospitalization. The Clinical Liaison RN may be assessed for success of achieving Value-Based Enterprise measures.

Major Challenges:

• Demonstrates ability to cope with ambiguous and changing environment.
• Demonstrates the ability to remain calm under pressure.
• Works well independently; able to work effectively without day-to-day supervision.
• To establish and maintain positive working relationships with facility customers and JV home health agency and hospice staff.
• To prioritize multiple tasks and work in a demanding, active setting.
• Understanding purpose and function of Value-Based Enterprise agreement between Providence and JV for home health and hospice care coordination.

Patient Population Served: Not Applicable

Position Specific Responsibilities:

• The job duties listed are essential functions of the position. However, other duties may be assigned, and may also be considered essential functions of the position. The caregiver must be sufficiently fluent in the English language to satisfactorily perform the essential functions of the position. The degree of fluency required will vary depending upon the nature of the position. Caregivers are expected to honor the Mission, Values, Vision and Promise and adhere to the Code of Conduct, policies and standards of their organization. For direct patient care roles: Performs and maintains currency of essential competencies as required by specific area of hire and populations served.
• HOME HEALTH AND HOSPICE ADMISSIONS
• Assess referrals for appropriateness for home care and hospice to include medical, physical, social, and emotional status, home environment and family's acceptance and ability to care for the patient in the home and determine the need for equipment.
• Coordinates discharge planning for hospital inpatients to home health and hospice service needs of referral sources including physicians and authorized mid-level practitioners (e.g., ARNP or PA) including but not limited to those who are hospital-based, work in clinics, physician offices or elsewhere in the community.
• Provides home care information/education at meetings with hospital service, utilization review/discharge planners/case managers, patients and patient's families and educates hospital medical and physician/mid-level staff, patients, and patient's families to available home care services.
• Acts as liaison between patients, families, payors, physicians, Providence discharge planners, and the network providing complete physicians' orders, referral information to the network intake department.
• Assumes initial responsibility with Hospital discharge planning team for assessing patient/family needs for Home Health, Hospice and consults with the attending physician, Hospice Medical Director, intake team and other staff members as necessary.
• Plans for admission of patients to Home Health, Hospice in coordination with agency representative, patient/family, Hospitalist and primary physicians/attendings, Medical Directors and hospital case manager/discharge planner.
• Contributes to the clinical determination of a patient's appropriateness for Home Health and Hospice services consistent with applicable policies and admission criteria and in conjunction with patient's physician or appropriate mid-level practitioner.
• Facilitates transition of patient/family to primary nurse and other members of the hospice Interdisciplinary Group (IDG) as indicated for patients who elect hospice after determined to be hospice eligible.
• Coordinate the expansion and implementation of the GIP (General Inpatient Care) Hospice Program in conjunction with hospice team.
• Attends appropriate meetings to promote Home Health and Hospice referrals and GIP as appropriate.
• Maintains and builds existing relationships with post-acute care providers by serving as a resource for education and information.
• Evaluates referrals received on hospitalized patient from a variety of care settings for appropriateness for Home Health and/or Hospice [or other in-home services programs as appropriate].
• Coordinates with the Inpatient Hospital Team and primary RN/MSW to ensure discharge planning is comprehensive and communicated efficiently.
• Appropriately documents activities in the Providence and JV's electronic medical system; tracks referrals received by nursing unit and accepted by each JV agency.
• Actively participates in development and execution of strategic initiatives that include increased Value Based Enterprise care coordination and discharge planning services for applicable post-acute care patients who will receive home health or hospice care following the hospital inpatient discharge.
• Attends scheduled meetings and engages in appropriate oversight communications with the Clinical Excellence Team.
• Assists patients/representatives complete and obtain Hospice Election Statements and hospice consents.
• Assists patient/representatives complete and obtain home health agency consents.
• Assists physicians/mid-level practitioner with the admission of patients onto Hospice services as appropriate, though only physicians may certify a patient is terminally ill and eligible for hospice.
• Discharges hospice GIP patients receiving care at the Hospital to home/SNF/Assisted Living Facility (ALF) as appropriate, in coordination with the JV hospice's care team.
• Provides staff and physicians with education regarding end-of life care, hospice and GIP.
• For routine home care hospice referrals, takes hospice evaluation and admission order and ensures appropriate staff, including Care Transition Associates, are notified to follow up that all services and products are arranged.
• Follows up with referrals to confirm all services and products have been arranged.
• All employees who have contact with participants/residents/ patients/clients are expected to promote the Patients' Bill of Rights and Responsibilities and understand basic procedures for receiving and documenting grievances in order to initiate the appropriate process for participant concerns.
• Acquire current knowledge of multiple managed care contracts and network provider subcontracts.
• Work cooperatively with Hospital discharge planning team to identify patients who would benefit from homebased care and to effectuate efficient and effective discharges in cooperation with patient's physician/mid-level provider.

Education and/or Experience:

• Required Education sufficient for licensure
• Preferred Bachelor's Degree Nursing
• Required Minimum 1 year Full-time experience in clinical role
• Preferred Liaison, care coordination experience.
• Preferred Health care industry experience.
• Preferred HomeCare HomeBase EMR experience.
• Preferred Epic EMR experience.

Skills:

• Mathematical Skills: Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percentage.
• Language Skills: Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from leaders, team members, investors, and external parties. Ability to communicate clearly, sensitively and in a supportive professional manner with patient/family/caregivers, co-workers and public. Strong written and verbal communications in English and excellent customer service communication skills by phone, email, and face-to-face.
• Other Skills and Abilities: Ability to articulate and embrace integrated healthcare at home philosophy. Understands the purpose and function of Value-Based Enterprise agreement between Providence and JV for home health and hospice care coordination. Ability to maintain positive, collaborative, and constructive interpersonal relationships. Understands and practices the principles of effective teamwork. Strong skills in prioritizing multiple tasks, facilitating complex problem solving and the ability to work with families/representatives in crisis. Ability to follow appropriate communications channels and excellent negotiation and public relations skills. Demonstrates the ability to remain calm under pressure and adapt to an ambiguous and changing environment.

Certifications, Licenses, and Registrations:

• Active and unencumbered Registered Nurse license in state(s) of employment required.
• Current CPR certification required

Physical Demands and Work Environment: The demands of this role necessitate