Goals Of Care APN

Compassus San Antonio , TX 78245

Posted 2 weeks ago

Current Compassus Colleagues: Please apply via Workday.


The Goals of Care Advanced Practice Nurse is responsible for modeling the 3 Company values of Compassion, Integrity, and Excellence, and for promoting the Compassus philosophy, using the 6 Pillars of success as the foundation. S/he is responsible for upholding the Code of Ethical Conduct and for promoting positive working relationships within the Company, among all departments, and all external stakeholders. The Goals of Care Advanced Practice Nurse uses the nursing process to provide assessment, planning, implementation, and evaluation of the patient and family in collaboration with the Medical Director, identifies needs and goals of care. S/he helps the patient and family maintain their maximum level of comfort and coping, being sensitivity to the needs of the seriously ill. The Goals of Care Advance Practice Nurse serves as clinical and educational role model and mentor; provides care and support in collaboration with the primary care team; and ensures compliance with practice standards and codes. S/he flexes schedule to meet agency needs. S/he is responsible for applying the rules and regulations of state and federal regulatory agencies and other certified agencies.


Regulatory Compliance Pillar of Success

  • Reads and incorporates into practice the policies and procedures for Compassus.

  • Articulates the framework for regulatory compliance from federal perspective and the application/ implications for the Goals of Care Advanced Practice Nurse.

  • Adheres to company expectations for the protection of confidential information.

  • Complies with all federal, state, and local laws, rules, and regulations to which the Company is subject.

  • Protects the confidentiality of all patient, colleague, and Company information.

  • Cooperates with internal and external surveys, audits and investigations, providing truthful and accurate information.

Colleagues Pillar of Success

  • Works collaboratively in a team environment.

  • Promotes effective communication and seeks solutions to concerns raised.

  • Complies with all federal, state, and local laws, rules, and regulations to which the Company is subject.

  • Protects the confidentiality of all patient, colleague, and Company information.

  • Cooperates with internal and external surveys, audits and investigations, providing truthful and accurate information.

Quality Pillar of Success

  • Exhibits compassion, dignity, and respect to our patients and families in all circumstances.

  • Works consistently to do things right the first time, in accordance with our core value of Excellence.

  • Makes efficient and effective use of resources to complete assignments.

  • Demonstrates personal responsibility for professional development and training.

Service Pillar of Success

  • Exemplifies the Compassus Service Commitment in all actions.

  • Demonstrates willingness and ability to adjust to change rapidly and is flexible in a variety of situations.

  • Is open, receptive, approachable, and quick to respond to direction and assignments.

Growth Pillar of Success

  • Engages all Colleagues in the Growth goal.

  • Assesses opportunities and develops local initiatives to achieve stated, goals, based on systematic analysis of supporting data and in concert with appropriate Company resources.

  • Tracks and communicates progress toward goals.

Financial Responsibility Pillar of Success

  • Participates in the development of and adheres to the budget.

  • Analyzes available data to make sound financial decisions, lowering/eliminating costs where possible.

  • Makes efficient and effective use of time, Colleagues, and other resources, balancing short-term results with long-term organizational health.

Position-specific Responsibilities

  • Supports agency and corporate policies, goals, and objectives:

  • Promotes a positive working relationship with colleagues, agency and all stakeholders, displaying the ability to work with an interdisciplinary team and take directions.

  • Attends and participates in staff meetings, educational programs and community events, as requested.

  • Promotes palliative care and hospice philosophy.

  • Communicates identified needs and potential solutions to supervisor.

  • Performs patient-centered discussions of treatment goals:

  • Completes initial patient screenings, patient history and physical examination; along with a psychosocial assessment of patient and family.

  • Analyses all patient data and determines the need for appropriate follow up visits.

  • Educates patient and family to enhance understanding of disease processes and plan of care, including discussion of treatment options to ensure informed decision making.

  • Assist patients in accessing appropriate services and resources in the community to improve overall health and well-being

  • Provide emotional support to patients and their families to improve transitions, adjustment to illness and adherence to treatment plan.

  • Empower patients to take control of their health care by encouraging appropriate goal-setting and discussions about advance care planning/completion of advance directives.

  • Assists patients and families in identification of goals of treatment and ongoing plans of care and communicates these goals to the Interdisciplinary Team (IDT).

  • Collaborates with Medical Director on current palliative care census to determine modifications to identified goals of care.

  • Complies with applicable laws and regulations with respect to Collaborative Agreements.

  • Has prescriptive privileges should the need arise.

  • Responsible for the preparation and maintenance of accurate patient records, charts, and documents to support sound medical practice and reimbursement.

  • Initiates reimbursement for services rendered, possessing knowledge of appropriate coding to compliment services.

  • Assist in the development of clinical practice guidelines/standards in support of quality palliative care.

  • Delivers quality care while maintaining company metrics pertaining to productivity.

  • Assist with education and training for Program staff and within the hospital and community settings.

  • Advocates for improvements in palliative care through participation in professional, private, and governmental groups.

  • Defines goals for professional growth and participates actively in professional activities and organizations.

  • Engages in active and frequent self-care activities for personal and professional growth and longevity.

  • Adhere to the practice of confidentiality regarding patients, families, staff and the Organization.

  • Collaborates and/or Communicates with Medical Director, Attending Physician, Hospital Staff and IDT:

  • Collaborates and/or communicates the needs of patient for clinical and psycho-social interventions.

  • Assists in identifying the need for intervention of other IDT members.

  • Completes and submits required paper work within 24 hours of visit completion.

  • Educates patient and caregiver regarding:

  • Care of patient

  • Disease process

  • Goal Setting

  • Symptom control

  • Treatment options

  • Advanced care planning

  • Performs other duties as assigned.

KNOWLEDGE AND SKILLS To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and/or Experience

Master's degree in Nursing. Minimum of five years nursing experience; clinical nursing care in oncology, hospice, geriatrics, intensive care preferred. Licensed to practice in state. Maintain or willingness to obtain Board Certification in Hospice and Palliative care is encourage.

State Specifics:

  • All States except Iowa: Current collaborative physician agreement in place.

Mathematical Skills

Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percentage.

Language Skills

Ability of effectively present information and respond to questions from Leaders, Colleagues, patients and family members, and the general public. Ability to successfully write professional correspondence. Ability to read, analyze, and interpret periodicals, professional journals, technical procedures, or governmental regulations.

Reasoning Ability

Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, or schedule form.

Computer Skills

Proficiency in Microsoft Office Suite.

Other Qualifications

Strong organizational and interpersonal skills. Strong written and verbal communications. Ability to document as required by regulations.

Certifications, Licenses and Registrations

A valid driver's license and auto liability insurance. Certified, or eligible, as a Clinical Nurse Specialist or Nurse Practitioner.

Other Skills and Abilities

Ability to understand, read, write, and speak English. Articulates and embraces hospice philosophy. Ability to work a flexible schedule, to include some evenings and weekends. Ability to maintain confidentiality of information, such as patient and Company files. Must be able to travel.

PHYSICAL DEMANDS The physical demands described here are representative of those that must be met by a colleague 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 colleague is regularly required to use hands to finger, handle, or feel; talk and hear. The colleague frequently is required to stand, sit, and reach with hands and arms. The colleague is occasionally required to walk; climb or balance; stoop, kneel, crouch, or crawl; and taste or smell. The colleague must frequently lift and/or move more than 50 pounds. Specific vision abilities required by this job include close vision.

WORK ENVIRONMENT The work environment characteristics described here are representative of those a colleague encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

There will be possible exposure to infectious diseases through working with clinical caregivers. The noise level in the work environment is usually quiet. Travel beyond assigned service area may be required.

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Goals Of Care APN