The home based palliative care Advanced Practice Nurse (APN) provides direct care to individuals with advanced, complex illness at home as well as support and education to their families and/or caregivers. The MGH Home Based Palliative Care Program (HBPC) utilizes an NP consultative model in collaboration with a patient's primary care physician or subspecialist and with the support and supervision of the Home-Based Palliative Care (HBPC) Medical Director. Within this model the APN is responsible for the assessment and diagnosis of advanced palliative care, geriatric and general medical issues, prescribing treatment when appropriate and guiding patients and families through goals of care discussions and advance care planning.
The HBPC team is an interdisciplinary team consisting of a physician Medical Director who is board certified in Palliative Care and Hospice, palliative care certified NPs, a dedicated palliative trained social worker and a project manager/scheduler. As part of an interdisciplinary team the APN is expected to support the other providers and staff within the service and play a role in the clinical and non-clinical development of the service. From time to time the HBPC Program and its staff will also participate in new pilot and program development.
Given the independence inherent in-home based care, the APN is expected to be highly professional, mature and comfortable asking for the help/support of his/her team members as well as flexible and comfortable communicating across care settings and with a broad range of both clinical and non-clinical staff. The APN is also expected to conduct him/herself in a manner which is HIPAA and Joint Commission compliant, follow the Unit's code of conduct and be guided by the MGH Mission, Credo and Boundaries. This is a travel intensive role where the primary location for providing care is in the patient's home.
The HBPC Program was designed to improve care for patients with advanced complex illness living at home. Patients enrolled in the HBPC Program receive: an in-home comprehensive palliative care assessment which includes the physical, social, emotional and spiritual domains of care; comprehensive plan of care development; pain and symptom assessment and management; advance care planning including coordinating family goals of care meetings; triage to other community medical, social and volunteer resources as appropriate; coordination and care transitioning between home and inpatient services (hospital, assisted living, long term care); coordination of services with home care agencies; and referral for hospice services.
HBPC home visits are scheduled Monday-Friday during normal business hours and the HBPC clinicians are available during those hours to address clinical questions. During nights and weekends issues are referred to the primary care physician or subspecialist.
The project manager/coordinator receives and schedules all referrals and triages calls to the administrative office, paging the appropriate clinician when needed. Initial consults with an NP are scheduled based on urgency and follow up visits with the HBPC providers are scheduled based on patient and family need rather than a templated schedule. Patients who fall outside of our enrollment parameters are referred to other services as needed.
The initial home visit/consult may last 1-2 hours, during which a comprehensive palliative care assessment is completed, documented in the medical record and shared with the PCP or subspecialist either through the EMR and/or through a conversation between the providers based on the clinical needs of the patient. The primary care clinician or subspecialist is notified of any changes in clinical status and or the plan of care.
There is a weekly HBPC IDT and the Medical Director and team members are available daily for clinical support or questions. If the patient is receiving simultaneous traditional home care services (skilled nursing, PT and/or OT), the NP will reach out to the provider to offer support as needed and to ensure the effective communication of the plan of care.
When appropriate the HBPC clinician will help support the patient and family with the transition to hospice and will discharge the patient from HBPC once the patient is enrolled in hospice. If the patient is hospitalized the HBPC team coordinates care with the In-Patient Palliative Care Service and/or communicates with the hospital-based care team as needed to ensure as seamless a transition across care settings as possible.
Patients may stabilize or improve while enrolled in the HBPC program and in those instances the patient is discharged from the program. A PCP or subspecialist may re-refer a patient in the future as clinically indicated.
Master's Degree in Nursing
Current Massachusetts licensure as a registered nurse in the expanded role (NP)
Current Federal & Massachusetts licensure to dispense Controlled Substances
National certification in advanced practice nursing (NP)