The Community Based Palliative Care Transition Care Coordinator (PTCC) serves as a professional, and qualified registered nurse (RN), or licensed vocational nurse (LPN), with the responsibility to practice his/her profession commensurate with his/her licensure, training and experience in accordance with the laws and regulations governing their practice in the state in which services are performed, and all guidelines of applicable professional and accreditation agencies.  The PTCC is responsible to work in collaboration with patients, their families and other caregivers, the patient’s primary care physician, and other specialists as appropriate, to deliver episodic acute care and chronic medical management for patients with progressive illnesses under the direction of the Palliative Care Advanced Practice Nurse (APN), or as directed by the plan of care and regulations of a patient’s home health episode, or hospice episode.

Goal:

Support patient and family transitional care needs across care settings (i.e. acute care discharges back to community setting, home health episodes, hospice, etc.), and through disease stage changes in support of the care and/or treatment preferences established through goals of care discussions.

Physical Assessment and Treatment:.

• Assess the patient’s and family caregiver’s needs and coordinates appropriate services (i.e. DME, home health care, hospice, etc.) as required either prior to the patient’s transition home from an acute care stay (hospital, SNF), or at any point in their care continuum post-acute.
• Develops a plan of care in collaboration with the palliative care APN based on his/her treatment plan that maximizes the health potential.
• Assists in all facets of care coordination for referrals.
• Provides disease management instruction and education to patients and their families.
• Provides clinical guidance to facility staff relative to patient care issues, assessments and interventions within scope of practice.

Administrative:

• Participates with care setting’s interdisciplinary team as appropriate (i.e. Home Health, hospice, housing based clinics, QAPI, care coordination, clinical instruction, utilization committee, re-hospitalization committee, etc.).
• Obtains necessary medical information regarding the patient's health status, current
  medications and goals of care from appropriate sources and transpose into EMR as appropriate.
• Acts as a resource to coordinate complex cases for safe and appropriate transition to other care settings.
• Attends required meetings to enhance team communication, coordination of services and quality of care.
• Coordinate additional services with other palliative care team members for example, APN and SW to assist client and family during any transition.
• Reviews policies and services with referred patients and/ or family
  caregivers or authorized patient representative, and obtains consent for medical care.
• Communicates with provider team and manager about staffing
• Communicates essential patient information to care setting clinicians who will be initiating care.
• Provides training and continuing education for staff.
• Assists in development of clinical practice guidelines/standards in support of quality care   
• Employs metrics and data tracking of census and referrals
• Assists with obtaining Physician orders as required.
• Responds to inquiries regarding care services and programs to accurately identify
  the needs of each patient.
• May have access to and use of personal health information ("PHI") as necessary to fulfill
  the above duties and responsibilities.
• Performs all functions in compliance with federal, state, local law and regulation, as well
  the policies, procedures, and practice standards of Hebrew SeniorLife
• Assists with Insurance eligibility and authorization process, when appropriate.
• Performs other duties as assigned.

III. Core Competencies:

Integrity:

• Follows policy and procedures as directed.
• Brings concerns forward appropriately to supervisor.

Compassion:

• Promotes an environment of high integrity and teamwork.
• Works collaboratively with patients and their family caregivers, physicians, supervisors and other staff to facilitate effective transitions from one care setting to another.

Customer Focus:

• Takes appropriate and timely measures to meet the needs of the patient, their family and care setting
• Maintains mature problem solving approach under stressful circumstances.

Innovation:

• Assists in problem solving strategies with the patient, family, PCP, and setting staff to facilitate safe care of the patient.

Financial Responsibility:

• Works collaboratively with Intake Department in verification of coverage or payment.

• Valid nursing (RN/LPN) License in the State in which service is provided.
• Minimum of 3 years nursing experience preferred.
• Minimum of 3-5 years of experience with home health, hospice/palliative care strongly preferred.
• Advanced certification in hospice and palliative nursing care (CHPN/CHPLN) preferred