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Advanced Illness Management Coordinator

Granite VNA


Reporting to the Chief Clinical Officer, the Advanced Illness Management (AIM) Coordinator delivers age appropriate care to the patient in the home setting currently under the care of home health with advanced stages of a serious illness. Care is provided in conjunction with their families and care teams, in order to bridge gaps between curative and comfort directed care. The AIM Coordinator provides expertise in symptom management visits and goals of care conversations. Ensures a smooth transition across all care settings by coordinating all aspects of clinical care and services have been arranged to meet patient/family goals. The AIM Coordinator will be an ambassador for all Concord Regional VNA services by providing education, in-services, and will provide guidance on how patients can access their home care and hospice benefits. This versatile position will cultivate relationships with a variety of professionals, peers, patients, and caregivers. RNs will supervise Licensed Practical Nurses and Licensed Nursing Assistants assigned to patients.


Essential Functions

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

  • Takes a lead role in ensuring the assessment, planning and coordination of symptom management visits within the home care episode. Facilitates smooth transition to hospice care when appropriate.
  • Attends or coordinates attendance at home care Interdisciplinary team (IDT) meetings.
  • Collaborates and shares expertise and knowledge with others as an education resource regarding hospice eligibility and symptom management services both internally and externally.
  • Collaborates and assists the Chief Clinical Officer in the development, revision and implementation of program policies and procedures.
  • Assures compliance with all state, federal laws regarding licensure and certification of the agency.
  • Maintains knowledge of the Medicare Conditions of Participation for Hospice.
  • Demonstrates responsibility to effectively coordinate the patient’s plan of care with all appropriate care teams through family meetings and team/patient care conferences.
  • Proactively identifies and works with members of the Palliative Care & Hospice interdisciplinary teams.
  • Builds effective relationships with members of the Palliative Care team.
  • Demonstrates flexibility in the role by accepting other duties as assigned for which qualified.
  • Develops and implements appropriate plan of care (POC) that complies with referral source orders, specific treatment measures, frequency/expected duration and discharge goals in partnership with the patient, healthcare provider, patient representative (if any) and/or caregiver(s) based on thorough assessment incorporating all aspects of patient limitations and goals, and potential discharge environment.
  • Documents accurate and ongoing assessment/reassessment, treatment and discharge of the patient: nursing interventions, patient response to care provided, patient/caregiver educational needs, problems, capabilities, limitations and progress toward goals. Documentation includes evidence of appropriate patient/caregiver teaching, and the understanding of these instructions in accordance with agency guidelines.
  • Engages the patient /caregiver in meaningful education as indicated per care plan.
  • Communicates with all physicians involved in the POC and other health practitioners related to the current POC.
  • Demonstrates responsibility to effectively coordinate the patient’s POC with members of the Interdisciplinary Team and other health professionals through family meetings and team/patient care conferences. Updates patient’s short-term/long-term goals as appropriate based on interdisciplinary team assessments and re-assessments.
  • Participates in interdisciplinary team, agency projects, committees, QAPI program and/or other activities upon request and approval from direct supervisor.
  • Attends Agency In-service programs.

Other Job Functions

  • Supervise Licensed Practical Nurses and Licensed Nursing Assistants assigned to patients according to federal and state regulations.
  • Coach, mentor and precept new nursing employees and students.

1. Graduate of an accredited school of nursing, accompanied by current New Hampshire nursing license, or compact state license through the Nurse Licensure Compact (NLC).

2. Three years of general medical/surgical or skilled/acute care nursing experience.

3. Two years of Hospice/Palliative Care experience.

4. One year of supervisory or charge nurse experience.

5. Certified Hospice and Palliative Nurse (CHPN®)

How to Apply:

To apply, please visit our website directly at Thank you and we look forward to reveiwing your application!

Salary Range:

based on experience and education

Job Location:


Date Added: March 25, 2021

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