The AIM Transitions RN Care Coordinator (RNCC) provides specialized nursing services to patients nearing the end of life. The Transitions Nurse manages a caseload of patients with advanced illness who are participating of the AIM Program. The Transitions Nurse provides care both in the home and through telephone support. He/She works within the 5 pillars of the AIM Program. The care provided focuses on care coordination, patient-coaching and decision-support, symptom management, advanced care planning, education relating to disease process and treatment options, psycho-social and spiritual care, and reduction of Emergency Room (ER) visits, inpatient hospitalizations and timely transition to hospice. Collaborates with Home Health Clinical Team to assure delivery of comprehensive care (skilled and palliative) to AIM patients. Other duties associated with the AIM program will be assigned as needed, including but not limited to precepting of new staff. This position requires a working knowledge of Medicare Conditions of Participation for home health care and hospice, California Department of Health Title XII regulations, CHAP Accreditation, OIG Work Plan and HIPAA regulations in addition to knowledge of population with advanced illness care needs.
RN from an accredited curriculum is required. Bachelor Degree in Nursing or health related field is preferred.
One year of acute medical experience - required
One year of acute medical experience - preferred
Oncology or palliative care experience - preferred
Direct patient care experience within the past five years - required
Understanding of home care and hospice services and regulations, Title XXII, Medicare Conditions of Participation; infection control principles; excellent working knowledge of the principles of palliative care and demonstrated ability to work with patients with advanced illness.
Productivity standards ability to meet productivity expectations (3-6 pt. visits per day, depending on
visit type and needs).
Complete AIM program training program, including completion of training post tests.
Successfully pass AIM Program competency exam on annual basis with demonstration of knowledge of symptom management, understanding end of life issues with appropriate interventions and understanding of the impact of cultural background on illness management.
Possess excellent interpersonal skills enabling the AIM Program RN to discuss difficult issues concerning clinical goal-setting and transition toward end of life care with patients, families and physicians.
Ability to develop and maintain strong relationships with Home Health and Hospice staff, self-starter with a high degree of initiative, motivation, flexibility, energy and creativity.
Ability to exercise independent sound judgment in planning and providing patient care.