JOB DESCRIPTION SUMMARY
The Clinical Liaison serves as the on-site representative for Suncrest Hospice at Hospital partners facility. This role is responsible for managing all hospice patients admitted to the General Inpatient (GIP) level of care within the hospital setting. The Clinical Liaison ensures smooth admissions, effective discharge planning, and ongoing case management of GIP patients in collaboration with hospital staff, hospice team members, patients, and families.
JOB FUNCTIONS/RESPONSIBILITIES
GIP Admissions
- Completes an initial, comprehensive, and ongoing comprehensive assessment of patient and family to determine hospice needs. Provides a complete physical assessment and history of current and previous illness(es).
- Facilitate and complete GIP patient admissions directly within the hospital.
- Collaborate with hospital staff, attending physicians, and hospice medical directors to ensure timely and appropriate admissions.
- Educate patients, families, and hospital staff about hospice philosophy, services, and the GIP level of care.
- Uses health assessment data to determine nursing diagnosis.
- Initiates the plan of care and makes necessary revisions as patient status and needs change.
Case Management of GIP Patients
- Provides professional nursing care by utilizing all elements of nursing process.
- Assesses and evaluates patient’s status by:
- Writing and initiating plan of care
- Regularly re-evaluating patient and family/caregiver needs
- Participating in revising the plan of care as necessary
- Counsels the patient and family in meeting nursing and related needs.
- Acts as Case Manager when assigned by Clinical Supervisor and assumes responsibility to coordinate patient care for assigned caseload.
- Assesses and evaluates GIP level of care, and works with team to facilitate transfer if appropriate.
Discharge Planning
- Lead discharge planning visits for GIP patients transitioning to a lower level of care (Routine Home Care, Continuous Care, or Inpatient Unit)
- Educate patient and families on Hospice Services.
- Coordinate safe transitions with families, hospital staff, and hospice field teams to ensure continuity of care.
- Document discharge plans, interventions, and patient/family education accurately and in compliance with hospice standards.
- Ensures that arrangements for equipment and other necessary items and services are available at time of discharge.
Communication
- Act as the liaison between hospital staff and Suncrest Hospice to ensure seamless coordination of services.
- Completes, maintains and submits accurate and relevant clinical notes regarding patient’s condition and care given. Records pain/symptom management changes/outcomes as appropriate.
- Maintain professional and collaborative relationships with physicians, nurses, case managers, and ancillary hospital staff.
- Maintains open communication with Intake team to process referrals in a timely manner.
- Provide ongoing hospice education to hospital staff to foster strong partnerships.
- Participate in hospital-based care conferences as appropriate.
- Assists the patient and family/caregiver and other team members in providing continuity of care.
- Works in cooperation with the family/caregiver and hospice interdisciplinary group to meet the emotional needs of the patient and family/caregiver.
Additional Duties
- Supervises ancillary personnel and delegates responsibilities when required.
- Assumes responsibility for personal growth and development and maintains and upgrades professional knowledge and practice skills through attendance and participation in continuing education and in-service classes.
- Actively participates in quality assessment performance improvement teams and activities
- Complete timely and accurate documentation of admissions, care plans, interventions, and discharges in the electronic health record