Job Summary:

Demonstrates through behavior Decatur Morgan Hospital’s mission, vision and values. The CTN  helps patients move through different levels and types of care before, during and after their hospital stay. The CTN makes sure all physicians therapists and other caregivers have the information necessary to deliver appropriate care to the patient in the appropriate setting. The CTN provides post discharge follow-up evaluations to ensure compliance with discharge instructions

Key Responsibilities / Essential Functions

1. The Palliative Care Coordinator supports the delivery and coordination of palliative care services for patients with serious, complex, or life-limiting illnesses across Decatur Morgan Hospital.
2. Works collaboratively with physicians, nursing, case management, social work, chaplaincy, and other members of the interdisciplinary care team to identify patients who may benefit from palliative care services and facilitate timely evaluation and support.
3. Assesses patient and family needs within the scope of the individual's professional discipline, including goals of care, psychosocial needs, barriers to care, caregiver needs, available support systems, and discharge or post-acute care needs.
4. Facilitates communication among patients, families, and the healthcare team to promote understanding of the patient's condition, treatment options, goals, preferences, and plan of care.
5. Provides education and support to patients and families regarding palliative care services, advance care planning, community resources, hospice services when appropriate, and other available supportive services.
6. Coordinates care across the continuum, including inpatient, outpatient, home health, hospice, skilled nursing, and other community-based services, to promote safe and effective transitions of care.
7. Serves as a patient and family advocate and assists the interdisciplinary team in developing care plans that are consistent with the patient's identified goals, values, and preferences.
8. Participates in efforts to improve outcomes for patients with serious illness, including reducing avoidable hospital utilization, readmissions, unnecessary delays in care, and barriers to appropriate transitions.
9. Maintains timely and accurate documentation of assessments, interventions, care coordination activities, and patient/family communication in the medical record.
10. Participates in development, education, and continuous improvement of the hospital's palliative care program, including identification of opportunities to improve referral processes, interdisciplinary collaboration, and continuity of care.
11. Demonstrates professionalism and consistently promotes respect, compassion, dignity, and effective communication with patients, families, and members of the healthcare team.

Minimum Knowledge, Skills, and Experience Required

Education/Licensure:
Must meet one of the following:

• Registered Nurse: Associate degree in Nursing required; Bachelor's degree in Nursing (BSN) preferred. Must hold a current license to practice as a Registered Nurse in the State of Alabama or otherwise be eligible to practice in Alabama.

OR

• Social Worker: Bachelor's degree in Social Work (BSW) from an accredited program required; Master's degree in Social Work (MSW) preferred. Must meet applicable Alabama licensure requirements for the position.

Experience:
Minimum of 2–3 years of relevant healthcare experience required. Experience in palliative care, hospice, acute care, case management, care coordination, oncology, geriatrics, or the care of medically complex patients is preferred.

Knowledge/Skills:
Strong communication, assessment, care coordination, and interdisciplinary collaboration skills. Ability to work effectively with patients and families facing serious illness and complex healthcare decisions.

Working knowledge of community resources, post-acute services, hospice and palliative care resources, advance care planning, and healthcare transitions preferred.

Must demonstrate the ability to work independently while functioning effectively as part of an interdisciplinary healthcare team.