Palliative Care RN, Boston

Position Summary:

Commonwealth Care Alliance's (CCA)Palliative Care Team, comprised of multi-disciplinary clinicians, will provide care consultation and delivery on an on-demand basis in addition to providing scheduled non-urgent services to dually eligible CCA members, a group of individuals with significant medical, behavioral, and social complexities that require intensive support.

The Palliative teams will reside at CCA's state - wide locations and will be comprised of nursing (MA/RN), advance practice (NA/PA), Behavioral Health (LICSW/LMHC or equivalent), and Chaplain (MDiv).

The Palliative RN reports to the Palliative Care Coordinator and is called upon to work within the interdisciplinary team to comprehensively evaluate and formulate a palliative management plan for members needing goals of care conversation, experiencing an acute event or significant change in condition and/ or end of life management and planning. The Palliative RN provides episodic advanced serious disease management, urgent visits, promotes preventative care and wellness, pain management, and augments the provision of end of life/palliative care.

The role also includes providing input to other palliative team members, outside providers and members' care teams on key care management/care coordination decisions, including the adjustment of the member centered care plan and identification of the need for durable medical equipment and services, consideration for re-stratification and planning for end-of-life location.

Supervision Exercised:

• None

Essential Duties and Responsibilities:

• Performs episodic urgent medical visits for palliative members to ensure that members are given timely and appropriate medical care regarding symptom management and education about disease trajectory and options available in order to avoid unnecessary emergency room visits or hospitalization. Visit includes a detailed history of present illness, review of systems, medication reconciliation, physical exam, recommendations in consultation with NP/PA or outside providers of appropriate studies and tests, development of a treatment plan, and evidence of follow-up through timely documentation
• Facilitates and/or delivers palliative care to members according to the guidelines deemed appropriate by CCA Palliative Leadership. Guidelines may vary based on the individual's goals of care, as CCA offers concurrent care for members with advanced, serious illness.
• Identifies and initiates a plan to resolve areas of opportunity to meet quality metrics.
• Provides regularly scheduled follow-up visits for members facing end of life/and limited follow-up visits for those needing palliative care consultation. Visits are inclusive of a history of present illness, review of systems, physical exam, medication reconciliation, recommendations for ordering of appropriate studies or tests, adjustment, or maintenance of an established treatment plan, and consistent follow up of the plan as evidenced in the documentation.
• Provides Intermittent Skilled Care as necessary (e.g., wound care,)
• Documents all activities and results using an Electronic Medical Record, in an effective manner while strictly adhering to CCA policies and procedures
• Adjusts the member-centered plan of care as necessary based on a significant change in condition. A change in condition is an event (hospitalization, acute illness, etc.) which results in either a short- or long-term change in need (examples include adding in Collaborative Contracted Partners, increasing personal care hours short term post hospitalization, or recommending durable medical equipment for a non-reversible functional change)
• Utilizing and depending on CCA internal resources, ensures that the plan of care is implemented in a timely manner.
• Provides end of life care to a panel (in coordination with Care Partners)in a manner that is consistent with helping the member and caregiver identify goals of care, anticipate changes needed as member's condition declines along the disease trajectory.
• Helps member and caregiver navigate end of life decisions related to goals, incorporating realism and safety in a way that
• also empowers them to make the decisions that are best for them.
• Shows an ongoing commitment to learning about the tenants of Palliative Care through ongoing pursuit of education
• Provide clinical care to members via telehealth technologies (video, chat, etc.) for a clinically appropriate clinical care and care management services.
• Outreach to potential and existing clinical partners like health homes promoting and educating about Palliative Care
• Participates in cross-organizational working groups to continuously improve team performance.
• Identifies and suggests improvements to clinical programs, initiatives, processes, policies, workflows, and projects.
• Participates in CCA Quality Improvement efforts.
• Participates in committees and workgroups that promote clinical excellence and help to advance CCA's mission and business objectives
• Participates in committees and workgroups that promote clinical excellence and help to advance CCA's mission and business objectives
• Provides coaching and mentorship to new employees as requested by CCA Palliative Leadership

Working Conditions:

• Must be willing and able to travel to member's homes in addition to working in an office environment
• Valid driver's license with no restrictions.
• Ability to be active and mobile across MA.

Required Education:

• Associate degree in Nursing

Desired Education:

• Associate, Bachelor, or master's degree from an accredited school of Nursing
• Certification in Hospice and Palliative Care strongly preferred

Required Licensing:

• RN licensure in good standing in Massachusetts

Required Experience:

• 3+ years in Medical Surgical, VNA or Hospice setting
• Experience working with Medicare /Medicaid populations or populations with significant complexity of medical, behavioral and social needs.

Desired Experience:

• Experience with electronic medical records preferred

Required Knowledge, Skills & Abilities:

• Demonstrate clinical competence in aspects of care management, assessment, care planning, and medical/surgical treatment
• Excellent interpersonal skills demonstrated by ability to interact professionally with culturally and educationally diverse staff and patients
• Ability to manage significant change
• Excellent communication skills
• Ability to teach, mentor, and coach
• Ability to quickly shift gears and move in a new direction without clear guidance
• Willing to learn and utilize telehealth technologies (video, chat, etc.), when appropriate, for a variety of clinical care and care management services.

Language(s):

• Fluency in English required
• Fluency in one or more of the following languages strongly preferred: Spanish, Portuguese, Russian, Nepalese, and Vietnamese

Other:

• This position will utilize standard office equipment, including a Cell Phone.
• Physical Requirements:
• The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job
• Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions
• While performing the duties of this job, the employee is regularly required to stand; use hands to finger, handle, or feel; reach with hands and arms; and talk or hear
• The employee is occasionally required to walk; sit; and stoop, kneel, crouch, or crawl
• The employee must frequently lift and/or move up to 10 pounds and occasionally lift and/or move more than 100 pounds
• Specific vision abilities required by this job include close vision, distance vision, and ability to adjust focus