Overview Works independently and in collaboration with physicians to deliver palliative care. The NP provides palliative medical services by managing the symptoms of acute and chronic conditions, assisting with communication and coordination of care, and developing treatment plans. Care is provided at home and in other care settings which may include outpatient clinics, hospitals, assisted living, independent living, and skilled nursing facilities. The NP orders treatments, laboratory, and diagnostic services, works closely with health care agencies to coordinate palliative medical care, and approaches all patients and referral sources with a customer service manner. The NP coordinates care with patient's health care team through planning and effective communication. Responsibilities Clinical Patient Care Management Provides palliative care for residents in their home or clinical setting in collaboration with physicians and/or medical directors in conformance with any protocols or guidelines established by or with the collaborating physician, where required by state and/or federal law. Performs medically necessary assessments meeting the requirements of Medicare Part B, Evaluation and Management (E&M) codes with accurately and timely documentation. Schedules all visits based upon medical assessment and/or the established individualized care plan for the patient. Orders and reviews appropriate treatments, lab, x-rays, EKGs, and other diagnostic procedures as indicated by a palliative plan of care and documents the treatment plan accordingly. Reviews results with collaborating physician if recommendations for treatment are required. When clinically appropriate, re-schedules another visit to follow-up on abnormal labs or test results. Reviews, signs, and dates consultation notes, adjusts in the treatment plan accordingly, and notifies collaborating physician. Collaborates with the physician, referring physicians and other healthcare professionals to ensure optimal delivery of patient care. Collaboration and coordination of care with referral sources including hospitals, assisted living facilities, nursing homes, group homes and primary care providers and specialists. Collaboration with business development, hospice and home health business units. Working with business development in the community to promote palliative education to appropriate stakeholders. Home Visit-specific Standards Conducts medical visits, as frequently as dictated by medical condition or by the established individualized care plan for the patient. Contacts collaborating physician or Medical Director if treatment of patient's condition warrants physician intervention or needs significant change in treatment plan. To the extent requested, provides the physician and referral sources with copies of the progress notes, test results and medication changes. Provides communication and education about disease trajectory and treatment plan to patient and family. Leaves business card and appointment card with patient and family and instructs on how to contact the nurse practitioner. Medical Record Documentation Always completes all medical record documentation promptly and in compliance with any applicable state and federal laws and regulations. Communication Educates patient and family about conditions or instances where Nurse Practitioner needs to be called. Informs patient and family of how to contact him or her. Promptly returns all calls. Communicates with collaborating physician and healthcare team. Establishes a frequency of communication standard with collaborating physician and healthcare team pursuant to patient needs and in conformity with state and federal requirements. Notifies collaborating physician of any significant medical issues relating to patient care