Registered Nurse, Facility Navigator

JOB DESCRIPTION SUMMARY

The Facility Registered Nurse Navigator, under the direction and supervision of the Hospice Director, provides patient consultation, assistance and education about VNA Health to skilled nursing facilities, residential care facilities as assigned and direct. In addition, initiates and conducts hospice patient admissions and is experienced in nursing, with emphasis on community health and/or hospice education/experience. The professional nurse builds from assessments to plan and direct services to meet the needs of individual and families within the facilities. The Facility Registered Nurse Navigator is the initial nurse in the patient assessment process and identifies a plan to meet the patient’s immediate needs, then hands off to the assigned RN case Manager to follow with the patient/family. The Facility Registered Nurse Navigator respects and promotes the mission, values and vision of VNA Health.

ESSENTIAL JOB DUTIES AND RESPONSIBILITIES

1. Function cooperatively with referral sources and Community Liaison team to:
   1. Facilitate referrals to Hospice and responsible for providing accurate, consistent and efficient admissions to hospice patients.
2. Evaluate potential patients and referrals from all sources for their appropriateness and eligibility for hospice.
3. Audit charts within facilities, to ensure compliance and regulations are met for hospice patients in facilities.
4. Consult and collaborate with physicians, discharge planning personnel, insurance Case Managers and other sources to facilitate safe, appropriate discharge and/or establish a coordinated plan of care.
5. Coordinate referral with appropriate agency contact to ensure timely response, admission and/or follow up with referral source. Establish and maintain lines of communication between VNA Health and referral sources.
6. Interview the patient, family, and/or caregiver and discusses the current needs, and any psychosocial factors that are relevant to the plan. Coordinate with Liaisons to complete referral information that includes intake data, essential background information, hospital course, and the plan of care.
7. Identify, coordinate and/or provide ongoing education to assigned referral sources regarding VNA Health services and programs.
8. Attend and participate in ongoing organization meetings, including but not limited to, interdisciplinary team conferences, staff meetings and in-service training.
9. Complete all referral and activity reports as assigned.
10. Develop and maintain relationships that support and enhance the mission of VNA Health and promote ongoing business development.
11. Completes an initial assessment of patient and family to determine immediate hospice care needs. Provides a complete physical assessment and history of current and previous illness(es). Admits to appropriate level of service/care.
12. Assesses and evaluated patient’s status by initiating and documenting the patient plan of care.
13. Uses health assessment data to determine nursing diagnosis.
14. Develops a plan of care that establishes goals, based on nursing diagnosis and incorporates palliative nursing actions. Includes the patient and family in the planning process.
15. Initiates appropriate preventative and rehabilitative nursing procedures. Administers medications and treatments as prescribed by the physician.
16. Counsels the patient and family in meeting nursing and related needs at the admission visit.
17. Provides health care instructions to the patient as appropriate per assessment and plan.
18. Assists the patient with identifying the needs of activities of daily living with emphasis on safety and optional comfort care.
19. Accountable for assessing financial resources and eligibility under various third party payor sources, Medicare and Medi-Cal.

Communication

1. Completes, maintains and submits accurate and relevant clinical notes regarding patient’s condition. Records clinical monitoring, changes/outcomes as appropriate.
2. Communicates with the physician regarding the patient’s needs and reports any changes in the patient’s condition; obtains/receives physicians orders as required for the admission process.
3. Teaches the patient and family/caregiver self-care techniques as appropriate. Provides medication, diet and other instructions as ordered by the physician and recognizes opportunities for health counseling with patients and families/caregivers. Works in concert with the other hospice Interdisciplinary Team members.
4. Inputs complete medication profile time log and assessment by end of shift.
5. Provides and maintains a safe environment for the patient.
6. Assists the patient and family/caregiver and other team members in providing continuity of care.
7. Works in cooperation with the family/caregiver and hospice Interdisciplinary Team members to meet the emotional needs of the patient and family/caregiver.
8. Provides a complete and succinct hand-off report to RN Case Manager assigned to the patient and to the on-call staff, as appropriate.
9. Has working knowledge of state, federal, local, and accreditation regulations in order to provide hospice services to community clients.

Additional Duties

1. Meets daily average productivity standards set by the agency.
2. Participates in Quality Management activities.
3. Ensures that arrangements for equipment and other necessary items and services are available.
4. Participates in educational programs to maintain skills and knowledge of current nursing practice.

The above statements are only meant to be a representative summary of the major duties and responsibilities performed by incumbents of this job.  The incumbents may be requested to perform job related tasks other than those stated in this description. All clinical staff are expected to participate as needed in variable shifts, including weekend rotation per staffing needs and departmental holiday rotation.

POSITION QUALIFICATIONS

1. Current and active California RN/LVN license.
2. Bachelor’s degree, preferred.
3. Minimum one year acute care experience required.
4. One year recent home health or hospice experience preferred.
5. Bilingual – Spanish preferred, but not necessary.
6. Current CPR certification. 
7. Licensed driver with insured automobile - in accordance with state and/or organization requirements.
8. Excellent observation, verbal and written communication skills, problem solving skills, basic math skills; nursing skills per competency checklist.
9. Ability to respond independently to life threatening situations.
10. Ability to reason, deduce and carry our complex multiple step processes.

PHYSICAL REQUIREMENTS 

1. Ability to lift 50 lbs.
2. Ability to push/pull 50 lbs.
3. Ability to stoop, bend, and squat.
4. Ability to walk up one flight of stairs.
5. Ability to walk one mile.
6. Ability to sit for one hour, minimum.
7. Visual and auditory acuity.

STANDARD OF PERFORMANCE: 

VNA Health Evaluation tool.