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Palliative Care Transition Navigator
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- The Palliative Care Transition Care Coordinator (PTCC) serves as a professional, and qualified registered nurse (RN), with the responsibility to practice his/her profession commensurate with his/her licensure, training and experience in accordance with the laws and regulations governing their practice in Texas, and all guidelines of applicable professional and accreditation agencies.
- The PTCC is responsible to work in collaboration with patients, their families and other caregivers, the patient s primary care physician, and other specialists as appropriate, in an active practice to deliver episodic acute care and chronic medical management for patients with progressive illnesses under the direction of the Palliative Care Advanced Practice Nurse (APN), or as directed by the plan of care and regulations of a patient s home health episode, or hospice episode.
- Assess the patient s and family caregiver s needs and coordinates appropriate services (i.e. DME, home health care, hospice, etc.)
- as required either prior to the patient s transition home from an acute care stay (hospital, SNF), or at any point in their care continuum post-acute.
- Develops a plan of care in collaboration with the palliative care APN based on his/her treatment plan that maximizes the health potential as part of a patient s home health episode.
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