Tracking Code

2022-14585

Position Type

Full-Time

Shift

Day

Job Location

Springfield, Illinois

Description

The Advance Care Planning (ACP) Facilitator assists patients with the advance care planning process. Initiates opportunities for ACP discussions at multiple encounters throughout the lifespan of patients, assesses the needs of the patient seeking ACP assistance, and makes referrals to other resources identified during the assessment. The ACP Facilitator designs an individualized ACP approach based on the patient’s illness, readiness to participate, fears and concerns, religious or cultural beliefs, among other variables. Assists patients in making informed healthcare decisions based on understanding, reflection, and discussion. Prepares and strengthens the role of the patient’s chosen healthcare agent, assists in the development of a plan that honors the patient’s goals, values, and beliefs for future medical care and develops strategies to effectively communicate the plan to those who will be responsible for interpreting it and making decisions consistence with the patient’s goals, values, and preferences. Provides emotional support to patients/families struggling with end-of-life care decisions.

Required Skills

1. Initiates and facilitates advance care planning with patients:

• Motivates patients to plan by employing motivational interview strategies
• Assesses the ACP needs of the patient and determine decision-making capacity
• Explores understanding of ACP and advance directives, past experiences with family or friends who were seriously ill, and what gives the patient’s life meaning
• Identifies potential barriers
• Assists patients in selecting qualified healthcare agents and completing advance directives
• Assists in making informed healthcare decisions
• Provides instructions for goals-of-care in the event of a severe, permanent brain injury with poor cognitive outcome
• Includes and prepares the patient’s healthcare agent when appropriate

2. Promotes patient-centered decision making:

• Assists patients with reflecting on and making healthcare decisions based on personal goals-of-care
• Serves as an intermediary between healthcare providers and patients to ensure frank ACP discussions occur regarding sensitive topics, such as DNR or DNI orders, feeding tubes, pain management, palliative or hospice care and choosing healthcare surrogates
• Supports patients, families, and caregivers as they cope with the emotional distress of medical conditions and navigate the healthcare system. Helps patients and families to understand and navigate the emotional, psychosocial, and related clinical issues that result from advanced illness.
• Mediates divergent opinions, conflicting values, and strong emotions that can occur among patients and their families during these conversations
• Supports culturally appropriate ACP conversations with patients and families, displays sensitivity in terms of timing and approachability

3. Creates plans that represent patients’ goals, values, and preferences:

• Ensures that patients’ wishes are documented in advance directives and the EHR
• Follows ACP processes and correct use of advance directives
• Adheres to state and national advance directive regulations and health system policies
• Shares advance directives and advance care plans with other healthcare providers when appropriate
• Follows incident-to billing requirements.

4. Enhance the patient’s and care team’s understanding of ACP:

• Provides education on the benefits of ACP
• Answers questions regarding ACP
• Acts as a support person and promotes correct use of processes
• Assists providers with determining when seriously ill patients are ready for palliative or hospice care

5. Identifies the need for more in-depth ACP assistance as the chronic illness progresses, which may include referrals to other resources such as palliative or hospice care.

6. Plays a consistent and active role in program development and growth:

• Maintains knowledge of current trends and practices in Advance Care Planning
• Attends appropriate trainings to ensure and maintain current knowledge basis
• Promotes patient engagement

7. Performs other related duties as assigned.

Required Experience

Education:

• Master’s degree of Social Work from an accredited program required.

Licensure/Certification/Registry:

• LCSW Required
• Respecting Choices Advance Care Planning Facilitator Certification within six months of employment.

Experience:

• Experience working with adults across the life span presenting with chronic or serious illness

Other Knowledge/Skills/Abilities:

• Excellent verbal and written communication skills; ability to solve problems creatively
• Ability to work across multiple sites of care and multiple members of a care team while managing competing commitments through clear communications
• Ability to work in a changing and ambiguous environment.
• Must possess strong oral and written communication skills, planning skills, problem-solving skills, and personal diplomacy skills.
• Demonstrates personal traits of a high level of motivation, team orientation, professionalism and trustworthiness.
• Excellent PC skills, including the use of Microsoft Office products. Familiarity with EMR clinical products preferred.
• Current driver’s license and transportation.