Nurse Practitioner --Palliative Care
Provides medical care and management to patients living with a serious illness, who are served by the home-based palliative program. Works with a cross-functional clinical and operational team, including the Landmark Health Medical Director, Director of Health Services, Market General Manager, and Corporate Palliative Program Lead in the development and/or implementation of medical management policy, clinical protocols, interdisciplinary care processes, and quality management programs. Dedicated to improving the well-being and quality of life of patients, this position collaborates with the PCP, and as needed, the health plan Medical Director and other health professionals, to develop patients’ goals of care in all phases of palliative care.
As primary point of care for patients enrolled in the palliative program, provides information, direction, and instructions to his or her interdisciplinary team members as needed to achieve patient’s goals and Landmark’s model of care goals, while providing specialized medical care for people living with a serious illness. This may include ensuring that the palliative interdisciplinary team provides patient education of disease, diagnosis, and disease progression, with a focus on relief of symptoms and distress. Services will include providing treatment options aligned with the patient goals and decision in coordination with the PCP and broader medical team.
- Practices in accordance with the respective state laws and regulations governing the practice of advanced practice nursing.
- Understands and complies with palliative care policies and procedures, including those that regulate home-based palliative services.
- Establishes and maintains effective relationships with patients, caregivers, and their legal representatives as well as PCPs and other collaborating physicians/providers in delivering care to patients living with serious illness.
- Performs an initial comprehensive assessment on all newly enrolled patients and periodically thereafter. Develops a patient management care plan upon enrollment and updates it as needed when changes in condition warrant or following hospitalization. Meets with patients, caregivers, and/or their legal representatives to review newly developed or modified care plans; involves the PCP in these meetings.
- Completes follow-up and post-hospital assessments according to documented standard operating procedure.
- Prescribes appropriate diagnostics and interventions to avoid unnecessary transfers/acute admissions.
- Consults with hospital physicians following notification of patient transfer.
- Educates patients, families, and/or their legal representatives in disease processes affecting patients and ways to manage them effectively, as well as to promote care plans that focus on relief from the symptoms and stress of one or more serious illnesses to improve quality of life for both the patient and the family.
- Participates in panel management meetings that include, but may not be limited to:
- Weekly case conference reviews
- Monthly staff meetings
- Quarterly Quality Improvement Committee meetings
- Continuing education programs
- Implements quality initiatives as directed by cross-functional team to ensure the highest standards of care and to promote the improvement of care management and delivery.
- Requires some participation in clinical on-call program during business hours and after hours.
- Keeps current on relevant medical and nursing research, technology, and related issues by attending continuing education courses, professional meetings and journal reviews.
- Perform related duties as necessary and other duties as assigned.