<ul> <li>Responsible for continuity of care and discharge planning from inpatient facilities. </li><li>Work with care management team to identify patients who may require Hospice services </li><li>Serve as a liaison with physicians, inpatient nurses, case managers and care manager. </li><li>Develop and maintain relationships with inpatient / outpatient institutions and contract nursing facilities. </li><li>Respond promptly to requests for information and provide information regarding VNA's hospice program to patients, families, physicians and other sources of referrals in a manner that does not delay hospice services. </li><li>Screen and process inquiries for admission to Hospice services. </li><li>Determine patient's appropriateness for service consistent with VNA policies and admission criteria and in conjunction with the patient's physician. </li><li>Assist with implementation and coordination of services required for discharged patients from inpatient services. </li><li>Plan for admission to VNA in coordination with Team Manager/PCC. </li><li>nform the Team Manager/PCC of unusual or potentially problematic patient/ family issues. </li><li>Responsible for assessment, planning and coordination for nursing home admissions. </li><li>Supervise the planning, implementation and delivery of direct clinical services to nursing home residents. </li><li>Work with nursing home staff to provide care as needed. </li><li>Maintain regular communication with attending physician, nursing home director and other nursing home staff concerning patient/family care needs in response to interventions. </li><li>Assist in case conferences and family meetings at hospitals and nursing facilities as appropriate. </li><li>Provide end of life educational programs/in-services to providers. </li><li>Develop ongoing relationship with referral sources, including physicians, to keep them informed of agency programs and to solicit feedback regarding services provided by the agency. </li><li>Attend IDT meetings as needed. </li><li>Consistently provides service excellence to all patients, family members, visitors, volunteers and co-workers. </li><li>Challenges current working practices identifies process improvement opportunities and presents recommendations and solutions to management. Engages and commits to the organization's culture of continuous improvement by actively participating, supporting, and promoting CCHC Pillars of Excellence. </li><li>Other duties as assigned. </li><li>Current LPN/RN license in Mass. </li><li>Minimum two (2) years LPN/RN experience required, five (5) years with one (1) year as a Hospice Nurse preferred. </li></ul>