As a compassionate non-profit organization since 1983, Chapters Health System is committed to enhancing the lives of those affected by advancing age or illness. Through our comprehensive system of healthcare choices, we deliver expert care and heartfelt support to guide the community during the aging and end-of-life journey. From hospice and palliative care for adults and children suffering with life-limiting illnesses to in-home and community-based services for frail but independent seniors, Chapters Health offers a wide range of support services along life's ever-changing landscape. We'll help you navigate your individual experience – empowering you with more choices, education and guidance for these important chapters of life. .
The RN Care Coordinator is responsible for coordinating the patient's care and ensuring continuous assessment of the patient's and family's needs and implementation of the interdisciplinary plan of care. S/he directs and supervises the care provided by LPN and hospice aide and oversees the care provided by other disciplines.
- Current Florida license as RN, or current licensure from another state plus a temporary Florida permit.
- Valid driver's license and automobile insurance in the State of Florida.
- Reliable transportation to meet visit schedule.
- Minimum one (1) year in-patient nursing, hospice, or home health experience.
- Ability to use equipment with visual and auditory mechanisms.
- Ability to effectively communicate in English.
- Flexible schedule to meet the needs of hospice patients.
- Ability to physically access any home i.e. navigate stairs and narrow spaces, tolerate heat and lack of air conditioning, in any area Company serves.
- Ability to manage the emotional stress of working with and caring for terminally ill patients and their families.
- Ability to perform the essential functions and physical requirements (including, but not limited to: lifting patients and/or equipment, bending, pushing/pulling, kneeling) of the job with or without reasonable accommodation.
"Previous experience working with an EMR/EHR (Electronic Medical/Health Record) system required"
- Assess patient/family and identify ongoing needs and necessary nursing interventions, including change in level of care.
- Coordinate patient care, including assessing psychosocial, spiritual care, and volunteer needs, and make appropriate referrals, as needed.
- Continually assess patient's eligibility for hospice care and facilitate medical review, as needed.
- Provide and manage direct care to patients and families as part of Interdisciplinary Group (IDG), incorporating psychosocial, spiritual, cultural, physical and biological components, and appropriate nursing intervention and follow-up.
- Coordinate the plan of care, ensuring that an individualized plan of care is developed that accurately reflects the patient's evolving needs.
- Demonstrate clinical skills regarding: case management, application of company policy and procedure, physical assessment, intravenous therapies, pain medication titration, symptom management, and patient/family relationships.
- Facilitate coordination of care and documentation for change in level of care, team transfer and hospice discharge.
- Update interdisciplinary group and other health care professionals about pending medical appointments/diagnostic testing and outcome/result(s).
- Consult, refer, and collaborate with other professionals to promote quality and continuity of patient/family care.
- Take verbal orders from physicians, ARNPs and physician's assistants.
- Educate patient, family, caregivers and other health professionals about disease process and decline, palliative interventions, care giving, dying process and safety practices.
- Report changes in the patient's condition to appropriate members of the IDG or other health professionals.
- Attend patient deaths and prepare body for transport
- Oversee disposal of medications.
- Provide appropriate bereavement interventions to the family and caregiver in conjunction with social services staff.
- Accept responsibility and is accountable for nursing actions: demonstrate an understanding of the legal consequences of nursing actions; request supervision when needed; perform within the guidelines established by the Florida Nurse Practice Act.
- Document assessment, plan, intervention and evaluation on appropriate Company forms with accuracy, timeliness, legibility, professional terminology and awareness of legal and regulatory implications.
- Document patient condition and decline to support hospice and level of care appropriateness.
- Request medical records from physicians, hospitals, laboratories and other outside sources for use to determine patient's eligibility for hospice.
- Review documentation of own care team and audit medical records to ensure compliance with standards and quality of care.
- Present concise and pertinent oral and written reports to IDG; respect and encourage input from all disciplines.
- Communicate accurately and completely to physicians, staff members, patients, families, and supervisors; utilize positive approaches when working with others.
- Facilitate care team meeting by incorporating input of LPN and hospice aide to establish, evaluate, and revise patients' plan of care and prepare for interdisciplinary group meeting.
- Direct and supervise patient care provided by other nursing team members.
- Schedule LPN and hospice aide schedule for own care team.
- Mentor LPN and hospice aide through demonstration of skills, providing feedback on job performance and coordinating activities to enhance job performance.
- Apprise Clinical Manager of changes in patient's condition, care needs and concerns of patient, family and other health care providers.
- Participate in orienting new staff, students, volunteers and board members.
- Participate on committees and projects, as assigned.
- Act as a resource to peers, students, orientees and other staff members.
- Participate in activities and professional development that enhance hospice nursing skills.
- Participate in the broad education process of the Company, both to the medical and lay communities.
- Exemplify behaviors supportive of internal mission statement.
- Pursue own professional growth through attendance at required inservices; i.e., safety, infection control, Right to Know Law.
- Establish professional goals for self and continually evaluate self in the attainment of these goals.
- Utilize supplies, equipment, medications, laboratory and patient therapies within the Company philosophy.
- Employ palliative and home care management modalities in care of the patient prior to hospitalization.
- Demonstrate knowledge of payment structures and paperwork necessary to change financial classes.
- Collaborate with Clinical Manager about clinical authorizations.
- Participate in interviewing and selection process of new hires.
- Provide input to Clinical Manager LPN and hospice aide job performance.
- Duties as assigned by the Clinical Manager.*