- Build empathetic relationships with patients and families.
- Educate patients and families on diagnosis, prognosis, and treatment options.
- Complete advance care planning and facilitate Goals of Care (GOC) discussions.
- Translate patient values and goals into clinical care plans.
- Coordinate care across multiple disciplines including home health, palliative care, and hospice.
- Analyze patient data and monitor progress towards outcomes.
- Engage internal and external resources to address social determinants of health.
- Educate internal and community partners on hospice and palliative care referral pathways.
- Maintain accurate clinical documentation and records.
- Participate in interdisciplinary team (IDT) meetings and case conferences.