The Front Line of Patient Care
Our nurse professionals embody what it means to provide the best patient interactions possible. They also advance the art and science of nursing in a patient-centered, healing environment.
Team Lead Nurse - Hospice/Palliative CareLocation: Portland, OR Additional Locations:
Job Number: 799379 Date posted: 06/10/2019
To ensure coordination of care and services provided to all patients receiving home care services in Hospice and Palliative Care Programs; to provide clinical support to patients and field staff; and, provide leadership support to program management. Key functions are to develop a coordinated admission plan of care for referred patients; facilitate coordination of disciplines and services; use problem-solving and critical thinking skills to facilitate, coordinate, and execute effective, timely responses to clinical problems as they arise for patients; mentor and coach field staff; and provide leadership in identifying process improvements to increase staff productivity.
- Referral&Admissions to Hospice&Palliative Care: Review referrals&evaluate patient/family needs in collaboration w/ other team members. Identify patient/family needs&assist staff to triage&prioritize admissions. Ensures timely evaluation&admission to appropriate palliative care program. Assure timely evaluation&admission by all members of the IDT. Provide clinical assessment&intervention as identified in the referral process. Make recommendations to modify the plan of care to expedite safe transition of care, reduce risks,&enhance patient outcomes. For complex or potentially unsafe caregiving plan, assist in identifying&coordinating alternative options to address current care needs, which may include on-site visit or telephone conference w/ healthcare team members&patient/family/caregivers. When appropriate, coordinate referrals out to contract&non-contract providers for members that require hospice or home based palliative care services. Develop&maintain expert level of knowledge&skills related to agency policy, state practice acts, applicable state&federal regulations, utilization mgmt,&qualifications for hospice&palliative care services. Provide leadership to ensure referral&admissions process&workflow flows smoothly&efficiently.
- Provide telephone support to patients&staff: Triage patient&family calls&work in collaboration w/ field staff to problem solve&facilitate follow-up (e.g., visits, procedures, medication orders, DME, other supplies requests, etc.) as needed. Serve as point of contact for clinicians to assist in facilitating visits&problem-solving. Mentor&coach field staff. Coordinate, expedite,&track referrals&transitions across care settings (e.g.referrals to home phlebotomy&wound program, transfers to general inpatient, ICF/SNF, respite,&across home care programs). Coordinate w/ after-hours staff to address when follow-up is needed to ensure continuity of care across shifts. Facilitate physician communication, visits&support. In collaboration w/ the Hospice Team Manager oversee the day-today staffing&patient schedules; problem-solve staffing challenges to meet patient needs. Conduct patient home visits as required to assist the program in meeting patient needs.
- Provide program support: Act as Kaiser Permanente ambassador to provide member information to care facilities (SNF/ICF, assisted living, adult foster care home,&residential care facilities)&problem solve/ facilitate any issues which present barriers to safe transfers&the provision of quality care (e.g. special equipment needs, symptom/behavior mgmt,&complex care needs). Ensure systematic&on-going contact w/ hospital staff&other Kaiser Permanente Departments (e.g. LTC, Expanded Care, DME, Hospital Care Coordinators, Clinic Social Workers, Clinic Case Managers, Pharmacy, Home Infusion Program, Membership Services, etc.) to share information&ensure safe transitions of care. Facilitate IDG Team conferences as requested. Provide education to staff to expedite safe transitions of patients across care settings. Participate in orientation of staff to the hospice&palliative care programs. Provide mentoring&coaching. When requested participate in peer review field visits w/ staff,&provide input into the staff annual performance process. Participate in process improvements&provide a leadership role in defining&implementing changes to improve processes. Participate in professional committees&task forces as requested. Ensure regulatory&compliance standards are met in collaboration w/ others in the inter-disciplinary health care team. Participate in quality&utilization mgmt activities. Participate in continuing education to incorporate&maintain up to date knowledge&best practices in hospice&palliative care.
- Participate in program after hours call rotation as needed. Other duties as assigned.
- Minimum one (1) year of experience as a registered nurse in the acute care setting preferably medical/surgical and/or critical care nursing.
- Minimum five (5) years of Hospice/Palliative Care nursing experience.
- Minimum one (1) year of leadership experience or commensurate experience.
License, Certification, Registration
- Current Oregon AND Washington RN license required upon hire/transfer.
- Valid state driver's license required upon hire/transfer.
- Basic Life Support (BLS) for Health Care Providers required within 2 weeks of hire/transfer.
- Triage/phone experience.
- Demonstrated critical thinking skills and ability to quickly identify and implement solutions in a high stress environment.
- Adaptable and flexible with highly effective, proactive, and positive problem-solving skills.
- Demonstrated ability to collaborate with physicians, ancillary providers, nurses, and patients to plan for transition of care to and from the home setting.
- Demonstrated ability to collaborate with team members in a positive manner to organize, coordinate and manage workflow. Solid computer and keyboarding skills and familiarity with using a computer for clinical documentation.
- Concise written and verbal communication.
- Strong organizational and time management skills.
- Demonstrated track record of positive participation in organizational and process changes.
- Able to perform complete physical, psychosocial, emotional, and spiritual assessments.
- Able to operate stethoscope and sphygmomanometer.
- Knowledge of Medicare, The Joint Commission, and State requirements and regulations for home care and hospice programs.
- Knowledge of Kaiser Permanente systems.
- Note: This position requires completion of a writing/typing test.
- Note: This position requires a reliable automobile to travel to and from patient homes.
- Minimum ten (10) years of experience as an RN with at least one (1) year in Kaiser Permanente.
- Experience in a non-Kaiser HMO and/or non-Kaiser hospice program.
- Experience with discharge planning, care coordination, or case management.
- Experience with EPIC and/or Health Connect.
- Nursing triage/phone experience.
- Oncology Nursing experience.
- Experience with identifying and implementing improvements to processes and work flows.
- BSN preferred. Will consider RN with documented three (3) years recent experience in Hospice or Palliative Care in lieu of degree.
- Certified Hospice and Palliative Care Nurse.
- Demonstrated customer-focused service skills.
- Thorough working knowledge of Medicare regulations for Hospice.
External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with federal and state laws, as well as applicable local ordinances, including but not limited to the San Francisco and Los Angeles Fair Chance Ordinances.
About Nursing & Physician Assistant Careers
Through professional practice and leadership, nurses at Kaiser Permanente continually advance the art and science of nursing. But we recognize that what we do is more than clinical practice. We believe that every interaction — whether it is with a patient, a colleague, a physician, or anyone else — has the potential to be extraordinary. And we find that approaching our daily routine with this in mind gives each and every action new meaning and allows us to focus on the moment, empowering us to deliver expert care.
No matter where you are in your nursing career, the size and scope of our organization means you have the resources, technology, tools, and support you need to make a lasting impact.
Physician Assistant Careers
Physician assistants play a powerful and important role in delivering high-quality, informative care. Working directly with patients, their families, colleagues, and supervising physicians, they are vital in defining the overall care experience.
Being a physician assistant at Kaiser Permanente is centered on promoting a healing environment — one that maintains a caring, comforting practice while honoring the unity of the whole patient: mind, body, and spirit.
See What People are Saying About Working at KP
Come introduce yourself to a member of the Kaiser Permanente team at an upcoming career or professional event. We look forward to meeting you in person.
Recently Viewed Jobs
You do not have any recently viewed jobs.