• RN Coordinator

    Job ID
  • Overview

    Make the most of every moment –it’s the heart of our philosophy and mission at Capital Caring, a leader in hospice and palliative care in the DC metro region. We live our mission of improving the care of people facing life-limiting illness every day and are seeking a dedicated, RN Coordinator to join our team!

    Our Core Values include:

    • Complete Customer Satisfaction
    • Culture of Trust
    • Leadership to Grow
    • We are all Learners and Teachers
    • Live within the Model



    POSITION SUMMARY: In accordance with NHPCO standards and policies of Capital Caring and Capital Palliative Care Consultants and the acute care facility, the RN Coordinator provides the primary coordination of hospital- based hospice and palliative care. The RN coordinator receives all hospice and palliative care referrals and arranges for admission to the hospice or palliative consultative service, interfaces with the patient/family, and with the attending physician. The RN Coordinator triages all incoming referrals and coordinates interdisciplinary team members required to best meet immediate needs of patient. In collaboration with the hospice and palliative care medical consultant (when applicable), the RN Coordinator initiates the care plan and discharge planning and communicates with the interdisciplinary team regarding patient goals and treatment plan. The RN Coordinator makes nursing assessments, judgments and treatment decisions based on customer needs and wishes and in accordance with level of professional skills. The RN Coordinator promotes Capital Caring and Capital Palliative Care Consultants programs to acute care facilities through collaborative relationships with the facility by providing opportunities for professional development and community education.

    1. RN Coordinator nursing services are provided in accordance with a plan of care and within accepted standards of practice. They include:
      1. Initial and ongoing assessment of the impact of the terminal diagnosis on the patient’s physical, functional, psychological and environmental needs and activities of daily living.
      2. Risk for pathological grief
      3. Cultural and spiritual implications
      4. Verbal and non-verbal communication patterns
      5. Implementing the individualized plan of care and recommending revisions to the plan as necessary
      6. Managing discomfort and providing symptom relief
      7. Specialized nursing skills related to palliative and end-of-life care
    2. Consulting with and educating the patient/family regarding:
      1. The disease process
      2. Self-care techniques
      3. End of life care
      4. The processes for dealing with issues of ethical concern
      5. Initiating appropriate preventive and rehabilitative nursing procedures
      6. Preparing clinical and progress notes that demonstrate progress toward established goal)s)
    3. Coordinating all patient/family services and prioritization of needs with the members of the interdisciplinary team
    4. Use of case management approach and referring to other services as needed
    5. Informing the physician and other personnel of changes in the patient’s needs and outcomes of intervention
    6. Determining scope and frequency of services needed based on acuity and patient/family needs
    7. Supervising LPNs and paraprofessionals providing services to the patient according to regulatory guidelines
    8. Participating in in-service programs
    9. Providing specialized hospice training to other staff, family members and informal caregivers to ensure adequate care
    10. On-going evaluation of patient/family response to care
    11. Assessing the ability of the caregiver to meet the patient’s immediate needs upon admission and throughout care
    12. Evaluating own needs to support and using identified systems to meet the need
    13. Applying specific criteria for admission and re-certification to hospice care to establish appropriate levels of care and the patient’s eligibility
    14. Communicating information using current process and technology available to the organization
    15. Participating in the hospice performance improvement program
    16. Professional nursing services may also include seeing, treating, and writing orders for hospice patients if State law permits the registered nurse who is qualified to do so,
    17. Works closely as a team member with acute care facility IDT, Capital Caring (CC) and Capital Palliative Care Consultants (CPCC) to provide quality and timely service to patients and their families with difficult to manage disease and end of life care.
    18. Explains hospice and palliative care philosophy, goals, and services to patients/families, nursing staff and medical staff to ensure understanding of principles of care.
    19. Assesses care options based on referral source and patient/family needs and secures a CC/CPCC referral.
    20. Obtains written referral from attending and secures all consent documentation.
    21. Confirms insurance source and/or hospice benefit.
    22. Responsible for census generation and daily coordination of activities in facility. Communicates this activity at beginning and ending of day to hospice and palliative care medical consultant (when applicable) to promote consensus, consistency, and continuity of care.
    23. Identifies opportunities/barriers to meeting patient/family needs. Identifies necessary resources to best meet needs of the customer.
    24. Completes a nursing assessment and collaborates with the IDT to determine the service line for care (palliative care or hospice care) most appropriate and initiates the consult to the appropriate healthcare provider.
    25. Initiates plan of care in accordance with nursing process. Identifies treatment plan in collaboration with patient/family, primary physician, consultant physician and other members of the IDT. Identifies problems, goals, and interventions. Revises plan of care as needed.
    26. Completes all documentation in a timely manner as required by regulatory standards and to meet standards of acute care facility and CC/CPCC to promote communication and accurate exchange of information to all team members.
    27. Contributes to patient and family counseling and education. Consults with and educates the patient/family regarding (1) the disease process, (2) self care techniques, (3) end of life care and, and (4) the processes for dealing with ethical issues.
    28. Collaborates with facility case manager/discharge planner and community agencies to coordinate plan of care and available resources.
    29. Assists in coordination of transfer of care to home or other facility.
    30. Works with IDT in monitoring treatments and medication utilization outside of traditional practice, always being conscious of optimal resource management.
    31. Procures discharge needs of patient/family (i.e. DME, medications, home care needs, community services) through vendor/agencies identified by CC/CPCC.
    32. Participates in quality improvement activities, QUAPI program and hospice sponsored in-service training.
    33. Serves on committees or teams as approved by the clinical supervisor/general manager.
    34. Refers all CC/CPCC deaths during hospitalization to Bereavement service follow-up.
    35. Evaluates own needs for support and uses identified system(s) to meet the need.
    36. Participates in facility committees relevant to professional role and those that promote CC/CPCC philosophy and ideals.
    37. Assumes responsibility for own professional growth and development in order to maintain and improve competence. Practices evidence-based specialty practice and maintains competence through personal advancement of education and educational opportunities offered by acute care facility, Capital Caring and National Hospice and Palliative Care professional organizations. Develops new skills by participating in ongoing education and maintaining knowledge of current nursing practice through journals, literature review, etc.
    38. Achieves expected productivity standard (based on patient visits and caseload) as defined by the organization and in alignment with best practices/the Capital Caring model.


    LICENSURE: Licensure in the jurisdiction of practice - from the Commonwealth of Virginia, District of Columbia, and/or the State of Maryland to practice professional nursing.

    EDUCATION: RN from accredited nursing program. BSN preferred.

    EXPERIENCE: Minimum of two years of public health/community health, medical/surgical or hospice nursing experience. Hospital based nursing a preference. Strong communication and counseling skills of added benefit. Certifications in Hospice/Palliative care a plus.


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