New Markets Travel RN

• Review medical records to identify hospice and palliative care services eligibility, physician orders, and to verify diagnosis.
• Identify if patient meets admission criteria in collaboration with primary care, specialty, and Agrace physicians. Collaborate with IDT and primary care provider to create HES for determination of hospice eligibility.
• Identify if patient meets admission criteria by assessing patient’s physical, pain, psychosocial, emotional, spiritual, environmental, fall, medication safety, and educational needs. Collect data from the patient, family, significant other and other health care professionals about immediate goals and needs.
• Serve as a consultant to patients and families about end-of-life issues and Agrace programs philosophies and services.
• Collaborate with manager regarding all patients deemed ineligible for hospice services.
• Serve as a resource and consultant for hospital/clinic staff, physicians, nurses, social workers, chaplains about pain, symptom management, end-of-life issues, hospice/palliative care philosophies and services.
• Serve as a consultant to patients and families about end-of-life issues and Agrace philosophies and services.
• Actively pursue relationships and develop partnerships with all referral sources to promote the benefits of Agrace services.

• Assess patients and family’s physical, pain, psychosocial, emotional, spiritual, environmental, and educational needs as outlined by the plan of care (POC).
• Collect data from the patient, family, significant other or other members of the interdisciplinary team and other health care professionals.
• Identify, interpret, and document assessment data collected in the nursing interview, physical assessment, and other health data.
• Document and report significant changes in condition or unusual incidents to appropriate IDT member such as client abuse/neglect, suicidal intent, harmful coping mechanisms or violence, etc.
• Collaborate with IDT and primary care provider to create HES for determination of hospice eligibility.

• Respond to patient and family needs or change in condition or need for acute patient intervention.
• Provide interventions, treatments, and pain management to patients and family to meet needs. Evaluate the effectiveness of pain management or other intervention and adjust to meet needs.
• Provide patient and family education on pain, symptom management, end of life, etc. Evaluate the effectiveness of education and adjust to meet needs.

• Formulate, implement, and revise individualized POC in collaboration with Interdisciplinary Team (IDT), patient, and family. The POC includes goals, pain management, interventions, education, discharge plan, etc.
• Develop reasonable and achievable outcome measures and establish priorities in the planning and provision of care.
• Read, understand, and follow the plan of care. Document interventions, outcomes, and changes in patient condition in electronic health record (EHR).
• Delegate visits to appropriate disciplines and manage visit sets.
• Oversee work of Certified Nursing Assistants (CNA) and Licensed Practical Nurses (LPN).

• Participate in meetings to plan and evaluate patient/family services.
• Primary Preceptor with onboarding responsibility for new staff and students.
• Participates in education and outreach.
• Participate in RN on-call rotation based upon location.

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