Comprised of multi-disciplinary clinicians, will provide care consultation and delivery on an on-demand basis in addition to providing scheduled non-urgent services to dually-eligible CCA members, a group of individuals with significant medical, behavioral, and social complexities that require intensive support.
The Palliative teams will reside at CCA’s state – wide locations and will be comprised of nursing (MA/RN), advance practice (NA/PA), and Behavioral Health (LICSW/LMHC/ equivalent).
The Palliative Advanced Practice NP/PA provides clinical oversight of members referred to Palliative Care
Conducts thorough assessments of members identified as having Palliative Care needs including but not limited to: accurate history and physical assessment, medication reconciliation, goals of care identification, psychosocial/spiritual needs assessment, symptom management identification and plan
Determines and documents appropriate follow-up plans in line with member goals and communicates these plans with member and caregivers
Completes ACP documents as appropriate
Engages other team members to help address needs of members, through participation in family meetings or referrals as needed
Collaborates with and provides recommendations for outside providers. Documents these suggestions and contacted providers
Provides oversight and coordinates prescriptions and delivery for members on service with Collaborative Care Partners and end of life panel
Completes documentation within 24 hours of visit
Engages with outside providers in a meaningful, partnership-driven way. Identifies and suggests opportunities for education that may help further understanding of Palliative Care tenants to continue engagement.
Participates in multidisciplinary team meetings and works towards Palliative Care strategic objectives
Mentor and coach new staff as requested
Problem-solves local issues and engages in professional conflict management
Identify and communicate opportunities for operational improvement under direction of Palliative Program Manger to improve the performance of CCA
Identifies and initiates a plan to resolve areas of opportunity to meet quality metrics.
Assesses appropriateness of incoming requests and team’s processes over time to suggest opportunities for improvement
Participates in work groups as requested for process or service delivery improvement
Provides education to stakeholders as requested
Shows an ongoing commitment to learning about the tenets of Palliative Care through ongoing pursuit of education