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Clinical Care
1) Conduct comprehensive in-home assessments, including physical, psychosocial, and spiritual evaluations.
2) Develop, implement, and adjust individualized care plans focused on symptom control, quality of life, and patient goals.
3) Provide expert management of pain, shortness of breath, nausea, anxiety, and other distressing symptoms in collaboration with patients medical team.
4) Prescribe medications, order diagnostic tests, and perform appropriate clinical interventions within scope of practice as needed.
5) Evaluate treatment responses & modify care plans in collaboration with medical and interdisciplinary team.
6) Occasional on-call responsibilities may be required.
7) Provide advanced care planning education and discussions, including but not limited to goals of care and advanced directives.
Care Coordination
1) Collaborate with physicians, hospice teams, home health agencies, social workers, spiritual care providers, and other partners to ensure high quality care in alignment with patient and family goals of care.
2) Facilitate referrals to hospice, home health, community resources or other services when appropriate.
3) Communicate proactively with patients, caregivers, and providers to educate and anticipate needs with goal of preventing avoidable hospitalizations in chronically ill patients.
Education & Support
1) Guide patients and families through advance care planning, goals-of-care discussions, and complex medical decisions.
2) Provide education regarding disease process, prognosis, symptom management, and treatment options.
3) Offer emotional support to patients and caregivers throughout the illness trajectory.
Documentation & Compliance
1) Maintain accurate, timely, and compliant documentation in the electronic health record (HRE).
2) Ensure all care follows best practices, regulatory guidelines, collaborative agreement, clinical guidelines, and organizational policies.
3) Participate in quality improvement, case conferences, and team meetings.
4) Ensure compliance with monthly and quarterly collaborative requirements set forth by state board of nursing if not in an independent practice state.
Position Qualifications
1) Master's or Doctoral degree in Nursing from an accredited Nurse Practitioner program.
2) Current Nurse Practitioner license in the state of practice.
3) National certification from AANP or ANCC required.
4) BLS certification up to date.
5) Valid driver's license and reliable transportation for home visits.
6) Strong clinical assessment, critical thinking, and communication skills.
7) Specialized training or certification in palliative or hospice care (e.g., ACHPN) is highly desirable.
8) Preferred experience in palliative care, hospice, geriatrics, or related field.
9) Ability to work independently in the field with strong problem-solving abilities.
10) Empathy, emotional resilience, and a deep commitment to patient-centered care.
11) Comfort with complex family dynamics, culturally sensitive communication, and end-of-life issues.
12) Proficiency with electronic medical records and mobile documentation tools preferred.
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