Home Care Nursing - Baystate Health

Req#: R23854
Category(s): Nursing, Home Care Nursing
Full Time / Part Time: Full-Time
Shift: First


The Hospice Inpatient Coordinator performs nursing services requiring the physical, psychological, emotional, and socioeconomic assessment in the care of the patient with a terminal and life limiting diagnosis. Assumes primary clinical responsibility for assigned patients from admission to discharge. Coordinates with other members of the hospice staff to assure a high quality of patient/family care and participates as an active member of the interdisciplinary team. Ensures close care coordination between the hospice team and the acute care team members.

Job Responsibilities: 

1) Clinical Practice/Clinical Assessment/Data Collection

Demonstrates knowledge of developmental stages for the applicable age groups and applies developmental theories and concepts when implementing care.  Establishes realistic goals and develops plan of treatment in cooperation with the patient, family and members of the health care team.  Demonstrates excellent physical assessment and care planning skills.  Demonstrates current knowledge of pharmacology and medication administration.  Performs skilled nursing service in predominately acute care facilities.  Manage patient caseload, adjusting visit frequency as needed, setting priorities, and providing support to the family.  Develops an individualized plan of care based on patient, utilizing assessment data and standards of care while maintaining fiscal responsibility.

2)  Demonstrates leadership skills and ability in the coordination of patient care and unit activities.  Demonstrates sound decision making skills in the coordination of patient care.  Participates with members of the health care team in problem solving patient and/or staff related conflicts in a way that demonstrates a positive, mature and cooperative manner

3) Clinical Practice/Coordination of Services

Assesses and revises goals and treatment plan as appropriate for high quality service to patients in collaboration with interdisciplinary team.  Coordinates care and discharge planning with other team members during case conference.  Acquires and maintains an expert working knowledge of all third party payers and regulatory bodies and agency policies on issues related to documentation and care provided.  Completes mandated documentation in a complete and timely manner while maintaining clinical records in accordance with agency policies.  Promotes coordination of services by communicating with program staff as well as the acute care team members.  Performs a thorough and complete assessment within established time standards.  Validates assessment data with members of the health care team.  Documents initial and ongoing assessment data.  Provides nursing interventions as identified by the plan of care including patient/family education. 

4)  Evaluates patient response to interventions with members of the health care team and provides care recommendations to ensure patient comfort and safety.

5) Nurse-Patient/Family Relationship/Pt/Family Health Education

Educates patient, family and staff on diagnosis, treatment program and resources available

6) Performance Improvement/Interprets Clinical outcomes/data to improve practice

Participates in performance improvement activities and record audits.  Adheres to established policies/procedures and standards of nursing care and practice.  Demonstrates clinically current knowledge, skill and competency

7) Professional Practice/Development/Education

Provides nursing care with kindness, sensitivity, and in a manner that preserves and protects patient autonomy, dignity, and rights.  Supervises other members of care team according to agency policies.  Assumes responsibility to keep informed of current changes and trends in the nursing profession.  Adheres to establish policies, procedures and standards of nursing care.  Demonstrates clinically current knowledge, skill and competency.  Collaborates with managers to provide appropriate observational and experiences for students and orientees.  Ability to be a team player and work within an interdisciplinary team (internal and external).  Attend and contribute to in-service programs.  Plans, demonstrates and supervises home health aide activities in the acute care setting.  Establishes and maintains therapeutic and collaborative relationships with members of the internal and external health care teams. 

8)  Communicates, collaborates and maintains relationships within the healthcare team.  Maintains professional boundaries within patient and healthcare team relationships.

9) Demonstrates accountability for professional practice, growth and development

Attends and participates in staff meetings on a regular basis and attends educational programs related to present nursing practice area.  Attends orientation, in-service, staff and any other departmental, agency or system-wide programs/meetings as requested.

10)  Provides education on hospice and palliative care to internal and external team members as well as the community at large.

11)  Supports hospice /palliative care activities as needed which requires weekend, holiday, and evening hours.

Required Work Experience:

1) At least three years of Med/Surg nursing with experience in end of life care.

Preferred Work Experience:

1) None listed.

Skills and Competencies:

1) Excellent judgment and communication skills.

2) Ability to work independently with attention to detail.

3) Strong collaboration skills with other care team members.

4) Computer experience.

5) Candidate will undergo drug testing and may be required to submit to random drug testing after hire.

You Belong At Baystate

At Baystate Health we know that treating one another with dignity and equity is what elevates respect for our patients and staff. It makes us not just an organization, but also a community where you belong. It is how we advance the care and enhance the lives of all people.



Assoc of Science in Nursing: Nursing (Required)


Cardiopulmonary Resuscitation – Other, Certified Home Health Aid – Other, Driver License – Other, Registered Nurse – State of Massachusetts

Equal Employment Opportunity Employer

Baystate Health is an Equal Opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, marital status, national origin, ancestry, age, genetic information, disability, or protected veteran status.

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