The self-directed Hospice and Palliative Care Public Health Nurse (HPCPHN) provides skilled nursing assessment, planning and coordination/care management across settings to patients in a private home, adult foster home, residential/assisted living care, intermediate care, skilled nursing facility, inpatient hospice facilities and hospital settings in order to maximize the comfort and health of patients and families consistent with hospice philosophy and CCS policies and procedures.

• Assume initial responsibility for assessing patient/family needs and consulting with attending physician, Hospice and Palliative Care Physician (HPCP) , other IDT staff members or other appropriate community or facility contacts as indicated by patient location and needs at the time of the assessment and care provision. Obtain data on physical, psycho/social, emotional and spiritual factors that may influence patient/family health status and incorporate that data into the plan of care. Facilitate advanced illness and/or end of life discussion with patient and family members to assist with choice of hospice or palliative care. Determine patient appropriateness for palliative care or hospice services (including hospice level of care and care site) in consultation with the HPCP. Case Management: assume primary responsibility for a patient/family caseload that includes the assessing, planning, implementing and evaluating phases of the nursing process; including scheduling visits to reflect patient care needs in order to maintain continuity of the plan of care; and advocate for patient and family. Participate as an active member of the IDT to coordinate information and services to update the plan of care. Maintain up to date patient records so that problems, plans, actions and goals are accurately and clearly stated and changes are reflected as they occur in accordance with CCS policies and procedures. Instruct primary caregivers, family members, employed caregivers and facility staff to provide hospice specific care as indicated. Attend weekly case conferences and actively participate in discussion of patient needs and care planning. Coordinate hospice care across settings to achieve smooth transitions of care and assure compliance with the hospice plan of care through communication and documentation for family members, caregivers, facility staff as appropriate. Supervise and document Hospice Aide care delivery every two weeks. Provide adequate emotional and clinical support at the time of death. Provide input into the bereavement assessment and plan of care. Provide phone triage and support to patients/families as needed and requested. Partner with agency management in the development and review of programs within Continuing Care Services Department. Facilitate the initiation of cost effective and safe hospice and palliative care and provide consultation to clinicians regarding appropriate care setting alternatives.
• Assure professional competency through maintaining state-of-the-art skills and knowledge consistent with state and Medicare regulations, Joint Commission accreditation standards, applicable nurse practice acts and agency policies. Participate in CCS and KP orientation and in service training for professional staff as well as agency and community programs as requested to promote professional growth and understanding of hospice and palliative care. Demonstrate familiarity with policies of the agency and rules and regulations of state and federal bodies which aid in determining policies. Participates in department quality management/improvement activities; including but not limited to clinical record review, occurrence reporting, focused studies, process and outcome measurement, peer review, continuous quality improvement projects. Partner in defining and achieving agency productivity standards.
• Participates in hospice and palliative care 24 hour call duty consistent with agency policy.
• Performs other duties as requested.