The Palliative Care Transition Care Coordinator (PTCC) serves as a professional, and qualified registered nurse (RN), with the responsibility to practice his / her profession commensurate with his / her licensure, training and experience in accordance with the laws and regulations governing their practice in Texas, and all guidelines of applicable professional and accreditation agencies.

The PTCC is responsible to work in collaboration with patients, their families and other caregivers, the patient’s primary care physician, and other specialists as appropriate, in an active practice to deliver episodic acute care and chronic medical management for patients with progressive illnesses under the direction of the Palliative Care Advanced Practice Nurse (APN), or as directed by the plan of care and regulations of a patient’s home health episode, or hospice episode.

Goal

Support patient and family transitional care needs across care settings (i.e. acute care discharges back to community setting, home health episodes, hospice, etc.

and through disease stage changes in support of the care and / or treatment preferences established through goals of care discussions.

SHIFT AND SCHEDULE

Full Time : M-F 8 : 00 AM - 5 : 00 PM

RESPONSIBILITES AND AUTHORITIES

Physical Assessment and Treatment :

• Provides and documents medically necessary services in accordance with provider (i.e. physician, APN) orders.
• Assess the patient’s and family caregiver’s needs and coordinates appropriate services (i.e. DME, home health care, hospice, etc.

as required either prior to the patient’s transition home from an acute care stay (hospital, SNF), or at any point in their care continuum post-acute.

• Develops a plan of care in collaboration with the palliative care APN based on his / her treatment plan that maximizes the health potential as part of a patient’s home health episode.
• Assists in all facets of care coordination for referrals.
• Provides disease management instruction and education to patients and their families. Refers to appropriate hospital or community programs as needed.
• Provides clinical guidance to facility staff relative to patient care issues, assessments and interventions within scope of practice.

Administrative

• Participates with care setting’s interdisciplinary team as appropriate (i.e. clinical standup, QAPI, care coordination, clinical instruction, utilization committee, re-hospitalization committee, etc.).
• Obtains necessary medical information regarding the patient's health status, current

medications and goals of care from appropriate sources.

• Acts as a clinical resource to coordinate complex cases for safe and appropriate transition to other care settings.
• Attends required palliative care team meetings and huddles to enhance team communication, coordination of services and quality of care.
• May coordinate additional services with palliative care APN to assist client and family during any transition.
• Reviews Midland Health’s policies and services with referred patients and / or family

caregivers or authorized patient representative and obtains consent for medical care.

• Communicates with Intake Nurses and the Clinical Managers to determine staffing capabilities.
• Communicates essential patient information to care setting clinicians who will be initiating care.
• Provides training and continuing education for staff as needed.
• Assists in development of clinical practice guidelines / standards in support of quality care.
• May assist with obtaining Physician orders as required.
• Responds to inquiries regarding care services and programs to accurately identify

the needs of each patient.

May have access to and use of personal health information ("PHI") as necessary to fulfill

the above duties and responsibilities.

Performs all functions in compliance with federal, state, local law and regulation, as well

the policies, procedures, and practice standards of Midland Health.

• Assists with Insurance eligibility and authorization process, when appropriate.
• Performs other duties as assigned.

Integrity

• Follows policy and procedures as directed.
• Brings concerns forward appropriately to supervisor.

Compassion

• Promotes an environment of high integrity and teamwork.
• Works collaboratively with patients and their family caregivers, physicians, supervisors and other staff to facilitate effective transitions from one care setting to another.

Customer Focus

• Takes appropriate and timely measures to meet the needs of the patient, their family and care setting staff.
• Maintains mature problem-solving approach under stressful circumstances.

Innovation :

Assists in problem solving strategies with the patient, family, PCP, and setting staff to facilitate safe care of the patient.

Financial Responsibility :

Works collaboratively with Intake Department in verification of coverage or payment.

QUALIFICATIONS

• Valid nursing (RN / LVN) License in the State(s) in which service is provided.
• Minimum of 3 years nursing experience preferred.
• Minimum of 3-5 years of experience with home health, hospice / palliative care strongly preferred.
• Advance certification in hospice and palliative nursing care (CHPN / CHPLN) preferred; required within 18-months of hire.

PROFESSIONAL REQUIREMENTS

• Maintain appropriate licensures and certifications.
• Practice within established protocols and provider (physician, APN) orders.
• Adhere to state regulations regarding practice act.
• Maintain a broad base of technical knowledge and skills to perform all assigned clinical / administrative duties.
• Knowledge of home / hospice regulations, end of life care services, and advance care planning.
• Demonstrate excellent teaching skills to relate medical information to the patient, family and other nursing staff.
• Possess excellent communication, interviewing and counseling skills, and the ability to explain medical problems and treatments in accurate and understandable lay terms.
• Must be able to coordinate and communicate effectively with colleagues, managers, and medical staff, and be able to teach and develop others.
• Must have the ability to prioritize, make decisions and set clear expectations for others.
• May have access to personal health information ("PHI") necessary to fulfill the above duties and responsibilities. Access to use and ability to disclose PHI is further defined by each organization / department.

Other Requirements

• Computer proficiency including the ability to utilize software programs used by the organization.
• Able to read and interpret technical instructions related to the care of the patient / client.
• Able to effectively deal with multiple changes.
• Able to engage in moderate amount of (90%) local travel.
• Able to provide proof of valid driver’s license, if applicable.
• Able to provide proof of valid liability insurance if assignments include driving own vehicle.
• Evidence of annual TB test and other state required tests.

Working Conditions & Physical Requirements

• Works in community care settings (home, SNF, ALF, and hospital).
• Able to stand, bend, stoop, squat, kneel and reach freely.
• Able to freely lift a maximum of 50 pounds.
• Able to assist patient / client with standing, walking, sitting, and rolling in bed.
• Visual / hearing ability must be sufficient enough to communicate written and verbally.
• Sedentary activity that may require occasional lifting, carrying, pushing or pulling up to 10 lbs in order to carry out daily job functions and related activities that may be required.

Last updated : 2024-06-25