Jennifer Nace

*Manages the direct care provided to home hospice patients, facility hospice patients and families by facilitating the coordination of care,monitoring payer source and all regulatory requirements. Responsible for direct supervision of home hospice interdisciplinary team. This includes team roles: RN,LPN,CNA, SW, and CP.

* Serves as a liaison to nursing facilities to enhance collaborative relationships and for problem solving related to patient care.

*Assists with patient visits and the intake of referral process as needed.

*Understands reimbursement and payer source implications to the plan of care and utilizes resources wisely and effectively.

*Honors and respects the customs,choices needs, and goals of each patient and family.

*Works independently and effectively in a variety of settings including private homes, nursing facilities, group homes and hospitals.

*Evaluates existing patients for ongoing eligibility for care according to organizational and regulatory guidelines.

*Completes competency visits for RN`s, LPN`s, SW`s, Chaplains and Hospice aides . Completes annual reviews for team members.

*Responsible for the coordination of daily activities of care delivery within the home hospice team.

* Reviews documentation for completion,accuracy, timeliness and compliance with regulatory and JCAHO standards.

*Facilitates IDT meetings assuring appropriate review of patients in accordance with applicable regulatory requirements and accreditation standards.

* RN Hospice case Manager for Senior Facility Team. Cased managed hospice patients in following facilities: Willow Valley The Glen and Lakes campuses. Quarryville Presbyterian Nursing Facility, Abbeville,Manor Care in Lancaster. The case manager for skilled, personal care, and independent living in the facilities, homes for Hospice and Community Care.

*Managed caseload of twenty or more patients.

*Had access to Point Click Care system in order to work with Facility nursing to assess pts comfort, discuss recommendations needed for comfort.

*Competent assessment skills. Competent collaboration with Facility nursing, physicians as well Hospice physicians to provide best plan of care possible.

*Attended Facility Care conferences to offer additional information for patients families as well as expertise in end of life changes.

*Effective collaboration with facility nursing , social workers and families to provide updates post each hospice nursing visit.

* Hospice nurse stationed at Wellspan York Hospital as part of hospice response team. Assessed patients with possible prognosis of 72 hours or less for possible eligibility for hospice admission while in hospital. Assessed for need of hospital level of care in order to be appropriate for a GIP Hospice admission in accordance to Medicare guidelines.

* Collaborated with hospital providers, Palliative Medicine Consultants, hospital staff and the Interdisciplinary Team to develop a comfort plan of care.

*Evaluates referred clients for eligibility, and existing patients for ongoing eligibility for care according to organizational and regulatory guidelines.

*Completed and documented admission and ongoing visits in accordance with Hospice policy and practice as well as Wellpsan York Hospital policy and guidelines.

*Anticipated, assessed, and responded to pain, and other symptoms of physical, emotional ,existential and spiritual suffering.

*Documented in both Hospital EHR and Hospice EHR in an accurate and concise manner. Provided documentation to support the limited prognosis, and level of care, changes to plan of care,disease progression and care needs.

*Collaboration with patient/family to explain hospice services during GIP admission. Explained if patient would have a possible prognosis of more than 72 hours would then need to discuss possible home with hospice verses admission to nursing facility. Explained no guarantee would be able to remain in hospital until time of death.

*Assisted with f/u visits as a waiting patient until discharge plans in place. Explained to patient and families exactly what services Hospice could provide in home. Allowing patient/family to decide if care in home is possible verses need for nursing facility.

* collaboration with Social Work to inform when additional care in home needed prior to discharge home with hospice.

* End of life education, active listening and support provided to patients and family at bed side. End of lifer education and support provided to hospital staff.

RN CM for HCC Facility team. Case managed over 28 patients combined case load at following facilities: Garden Spot Villages, Maple farms, and Fairmont Homes.

*Planned and delivered care to patients utilizing competent assessment skills,planning, interventions, implementation, and evaluation;and effectively interacted with patients,families, and other interdisciplinary team members while maintaining standards of professional nursing and clinical competency.

* Supervision to LPN and CNA to ensure patient visit needs were met.

* Provided end of life education to families, and facility staff as to help to prepare for death.

*Participated in care conferences with interdisciplinary team of facility and family to provide continuity of care.

Provided Nursing services, responded to inquiries, and referrals, and addressed urgent and ongoing needs for patients and caregivers. Performed admissions in settings of patients homes, group homes, personal care homes, assisted living facilities, skilled nursing facilities and hospitals.

*Assessed patients for appropriateness of hospice eligibility for hospice admission.

*Competently utilized critical assessment skills to meet needs in the moment for patients, families and care giver.

*Immediately responded to patient/family calls , made sure visits were made to address symptoms,issues,crisis,urgent admissions, anfdtime of death visits.

RN Supervisor Transitional Care Unit. Coordinated and prioritized care and situations in order to facilitate timely entry of Physician orders for new admissions, as well as current patients.

*Completed in house admissions and discharges.

*Performed alert charting and skilled nursing assessments.

*Collaborated with attending physician to obtain orders when appropriate.

* Assessed need for Hospital transport. Collaboration with family as well as ER Case Manager to alert of patient arrival. Prepared Face Sheet, MAR and TAR to be sent with pt to hospital.

* Collaboration with nursing from hospital to obtain report for admissions as well as provide report for hospital transfers.

*Administered medications via IV, Sub Q and IM injections. Effectively monitored and documented response.

* During Transitional Care Unit experience treatment opportunities performed: Wound Vac, peritoneal dialysis, TPN, LVAD, PICC lines, IV fluid/antibiotic administration, nebulizer treatments, Foley care.

RN Home Hospice Case Manager: Home Hospice area covered Reading, Stevens, Ephrata, Denver area. Driving was 600 miles a week.

* Position was accepted prior to knowing where service are would have been.

* Left after three months due to excessive driving, and burn out in only three months.

*Going form skilled nursing to home hospice case managing with 18-24 home patient's who were not managed. This RN did not understand hospice patients change quickly and were more difficult to manage.

* Assumed RN was doing something wrong.

* Felt defeated.

*Arranged to go back to Masonic Villages after 90 days completed at Hospice.

RN Shift Supervisor.

*Began as RN Supervisor of nights, then as a float RN Supervisor. Then finally, RN Supervisor on second shift.

* RN Supervised two floors normally. Approximately 40 residents to a floor. Along with LPN`s and CNA`s. At times would supervise three floors when needed with ease.

* Competent in supervision on any floor due to previous floating experience.

*Comfortable in skills enabling ability to work in many positions in order to help the team to provide superior care for residents.

*Performed alert charting, skilled assessments.

* Provided families with updates concerning their loved ones. Falls, skin issues to medication orders.

* Competent in assessing falls, and need for a patient to be sent out to ER.

* Promoted Team atmosphere. provided motivating and encouraging words to team to help to boost morale.

*Earned respect of team and fellow RN Supervisors.

*Collaborated well with Attending Physicians. Competent in knowing what orders could wait in Physician folder until next visit and when a phone call was needed for immediate orders.

*Made self present, visiting residents, helping to reduce falls by responding quickly to alarms and call bells. Encouraging staff to do same. Working as a team to reduce falls.

* RN Supervised locked Dementia unit. Experience with care of Dementia patients.