The PCRN plans and delivers direct patient care utilizing the nursing process of assessment, planning, interventions, implementation, and evaluation: and effectively interacts with patients, families and other interdisciplinary team members while maintaining standards of
professions nursing and clinical competency.
The PCRN is responsible for identifying and coordinating patient/family care to support patients and families in their home, skilled nursing facilities and other residential care facilities. They will coordinate and case manage using techniques that include person and family centered care planning, shared decision making, symptom management and counseling. The PCRN endeavors to utilize teaching, assessment, and intervention skills to provide symptom management and maximize the quality of life for the patients and families. The PCRN serves as a member of the IDT team and works to transition eligible patients to hospice care.
The PCRN establishes and nurtures external and internal professional relationships, maintains awareness of local medical markets, provides clinical assessments of prospective patients when necessary, and represents Gilchrist and its spectrum of services in a competent, professional manner consistent with the organization’s goals. PCRN may attend Hospital Dept rounds, provide counseling for Advance Care Planning, MOLST discussion and facilitation, and other assigned duties.
Education
Registered Nurse, Bachelor’s degree in Nursing or related field preferred
Experience
Minimum of three (3) years’ experience required with hospice, home health, critical care, ER, oncology or medical/surgical experience
Knowledge, Skills and Abilities
- Ability to market to and deal tactfully with customers (e.g. physicians, social workers, nurses, etc.), other possible referral sources, and the community
- Strong written and oral communication skills to communicate and relate effectively with patients, families, staff, other home-based providers, physicians and insurers
- Skill in effectively collaborating with a wide variety of service providers who are also working with the patient and with Gilchrist team members
- Skill in effectively working with patient/family with challenging psycho-social and socio-economic issues and circumstances
- Strong clinical assessment and documentation skills, as well as strong analytical skills in order to effectively guide patients and families around their care choices
- Self-directed with the ability to work with little supervision in a rapidly changing environment.
- Flexibility in scheduling and ability to manage multiple tasks simultaneously
- Strong computer skills including, e-mail, EMR, Word and PowerPoint applications
Licensures, Certifications
- Must possess current Maryland State license as a Registered Nurse
- Valid driver’s license and safe driving record and an automobile that is insured in accordance with GHC requirements
- C.H.P.N. certification within three years required
Physical Requirements
- Able to provide patient care that involves lifting, repositioning, moving patients and includes bending, reaching and twisting
- Ability to travel to patient locations; includes ability to drive, negotiate stairs and walkways, including uneven surfaces at private homes or facilities
- Sufficient dexterity to utilize electronic record keeping systems, computers/keyboards and or laptops and other related equipment
- Vision ability to assess patient’s health status using visual inspection and observation and to read medications, charts, calibration and monitoring devices
- Speech to verbally communicate to assess and impart information concerning patient status; to effectively complete patient/family teaching and to interact with internal and external health care teams
Working Conditions
- Must maintain productivity and quality standards as set by Gilchrist.
- Must have own reliable transportation
Principal Duties and Responsibilities
- Provides direct care to patients as prescribed in the Interdisciplinary Plan of Care in order to maintain the highest level of conform and quality of life and assuming primary responsibility for case management.
- Provide palliative support for referred patients and families, helps them understand their prognosis and guides them on the best programs to realize their treatment and life goals. .
- Evaluate and performs ongoing assessments and revises initial written plan of care with Interdisciplinary collaboration as the needs and conditions of the patient/family change.
- Professionally and compassionately explains Gilchrist programs to patients and families in situation-appropriate manner resulting in the admission of appropriate patients and positive impression of Gilchrist.
- Coordinate and supervise care, as prescribed in the Interdisciplinary Plan of Care in order to meet the needs of the patient.
- Attend and participate in weekly IDT meetings.
- Documents patient care reflecting nursing interventions, patient response to care, patient needs, problems, capabilities, limitations, progress toward goals and patient/significant other teaching and the understating of these instructions in the electronic medical record.
- Assess home care needs, being aware of the physical, emotional, and spiritual aspects and gathers data on social, economic and cultural factors which may influence health, well-being and quality of life.
- Assist patients, family members or other clients with concern and empathy; respect confidentially and privacy and communicates in a courteous and respectful manner.
- Completes timely electronic documentation of all visits and uses electronic medical record (EMR) systems effectively and efficiently.
- Participates in the weekend and holiday rotation to provide nursing service to clients when required outside of office hours.
- Coordinates community resources and other agency disciplines participating in patient care as needed.
- Ensures all HIPAA Privacy and Security Regulations, and other regulatory/compliance requirements are understood and followed.
- Maintains ongoing effective communication with other personnel who are involved with patient care.
- Performs job functions in a fiscally responsible manner consistent with policies, mission and vision
- Knowledge of an availability to perform admissions, intake information and conduct consultations as needed including, accurate explanation of the hospice benefit/Medicare, completion of a physical assessment, and entering the information/documentation into the electronic medical record.
- Other duties as reasonably required
All roles must demonstrate GBMC Values
Respect
I will treat everyone with courtesy. I will foster a healing environment.
- Treats others with fairness, kindness, and respect for personal dignity and privacy
- Listens and responds appropriately to others’ needs, feelings, and capabilities
Excellence
I will strive for superior performance in every aspect of my work. I will recognize and celebrate the accomplishments of others.
- Meets and/or exceeds customer expectations
- Actively pursues learning and self-development
- Pays attention to detail; follows through
Accountability
I will be professional in the way I act, look and speak. I will take ownership to solve problems.
- Sets a positive, professional example for others
- Takes ownership of problems and does what is needed to solve them
- Appropriately plans and utilizes required resources for various job duties
- Reports to work regularly and on time
Teamwork
I will be engaged and collaborative. I will keep people informed.
- Works cooperatively and collaboratively with others for the success of the team
- Addresses and resolves conflict in a positive way
- Seeks out the ideas of others to reach the best solutions
- Acknowledges and celebrates the contribution of others
Ethical Behavior
I will always act with honesty and integrity. I will protect the patient.
- Demonstrates honesty, integrity and good judgment
- Respects the cultural, psychosocial, and spiritual needs of patients/families/coworkers
Results
I will set goals and measure outcomes that support organizational goals. I will give and accept help to achieve goals.
- Embraces change and improvement in the work environment
- Continuously seeks to improve the quality of products/services
- Displays flexibility in dealing with new situations or obstacles
- Achieves results on time by focusing on priorities and manages time efficiently
Pay Range
$64,675.52 - $104,451.06
Final salary offer will be based on the candidate's qualifications, education, experience and alignment with our organizational needs.
COVID-19 Vaccination
All applicants must be fully vaccinated against Covid-19 or obtain a GBMC approved medical or religious exemption prior to starting employment at GBMC Healthcare, to include Gilchrist and GBMC Health Partners.
Equal Employment Opportunity
GBMC HealthCare and its affiliates are Equal Opportunity employers. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity and expression, age, national origin, mental or physical disability, genetic information, veteran status, or any other status protected by federal, state, or local law.
