ChristianaCare is currently seeking a full-time outpatient Nurse Navigator for our Supportive and Palliative Care practice in Newark, DE.
Work Schedule
- Monday-Friday, day shift
- No weekends or holidays required
Principal Duties and Responsibilities
Coordination of Care
- Assists Palliative Care staff with coordinating referrals from within and outside of Christiana Health Care.
- Completes a review of the patient upon initial encounter and periodically throughout navigation, matching unmet needs with appropriate services.
- Assists with identifying potential and realized barriers to care (e.g., transportation, caregiver support, housing, language, culture, literacy, role disparity, psychosocial, employment, financial, insurance) and facilitates referrals.
- Schedules and/or facilitates scheduling of appointments.
- Triage of family/caregiver phone calls, messages determining disposition of call. Coordinates response with Palliative clinicians based on clinical assessment and communicates treatment plan/recommendations to patient/caregiver.
- Organize inpatient palliative census and daily workload. Evaluate and triage consults by collaboration with the hospital team (bedside nurse, consulting providers).
- Support established inpatients in lieu of Palliative provider consult.
- Collaborates with the outpatient team for seamless transition.
- Provides psychosocial support to and facilitates appropriate referrals for patients, families, and caregivers, especially during periods of high emotional stress and anxiety.
- Supports discussions with patients and caregivers related to goals of care and end of life treatment decisions (hospice). Facilitates scheduling of family/provider meetings.
- Applies basic knowledge of insurance process (e.g., Medicare, Medicaid, third-party payers) and their impact on staging, referrals, and patient care decision toward establishing appropriate referrals, as needed.
- Monitors progress in achieving defined patient specific, clinical outcomes through performance improvement activities and outcomes.
- Manages care flow and navigates multidisciplinary treatment needs (including communication with and coordination of tests, and imaging).
Education
- Assesses patient and family learning needs to identify barriers to education (e.g., literacy, language, cultural influences, comorbidities)
- Utilizes “Teach Back method for patient education.
- Collaborates with multidisciplinary team to develop patients’ clinical treatment plan.
- Educates the patient/family/caregiver: diagnosis, treatment options, medication side-effect management, behavioral disturbance triage and guidance.
- Assists patient/family with appropriate information to make an informed decision.
- Maintain our inpatient patient education resources – (booklets on end-of-life expectations, pamphlets on our team and resources)
- Provide system education to nurses on nursing role in palliative care (by helping inpatient nurses understand how to interact with hospice, and be a nurse providing comfort care and advocating for basic primary palliative care for their patients)
Communication
- Facilitates communication among the Palliative Care team to prevent fragmented or delayed care.
- Acts as a liaison and advocate between the patients, families, caregivers, and health care providers to promote and optimize patient outcomes.
- Empowers patients and families through education and encouragement to self-advocate and communicate their needs.
- Adheres to established regulations concerning patient information and privacy.
Professional Role
- Contributes to Palliative Care program development, implementation, and evaluation within the healthcare system and community.
- Maintains required credentials and participates in learning to stay current with disease specific information and issues related to memory care, insurance, ethical issues.
- Contributes to the knowledge base of the healthcare community and in support of the Palliative Care role through activities such as involvement in professional organizations, presentations, publications, and research.
- Participates in system committees such as magnet, nursing council, safety, cultural competency/diversity, patient education, professional nursing council.
- Is a Mentor for students and other members of the team.
- Works with health improvement team to implement and evaluate new processes of care and patient flow which are determined by the team utilizing pathways, guidelines, and algorithms.
- Supports a culture of safety, respect, and commitment to excellence and inclusivity.
Education and Experience Requirements
- BSN required.
- Masters in nursing preferred.
- RN license or eligible for licensure in the state of Delaware, Pennsylvania, New Jersey, or Maryland
- Three or more years of combined clinical experience in clinical and/or administrative experience in casemanagement, clinical trials, older adult, palliative/hospice care preferred.
- Nursing Cert - Certified Hospice and Palliative Nurse (CHPN) - Hospice & Palliative Credentialing Center within 3 years of hire.
Special Requirements
- RN license or eligible for licensure in the state of Delaware.
- BLS
Qualified candidates should apply online and include a current resume.
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