Case Manager RN

To plan, coordinate and provide hospice care in accordance with the patient's plan of care.

• Coordinates hospice care by working with other team members as well as with the patients/family members to ensure needs are met.
• Evaluate the effectiveness of hospice services to the patient and family on an ongoing basis.
• Perform evaluations for hospice care along with informational visits as needed.
• Utilize the nursing process to provide professional nursing care.
• Consult with the attending physician and Hospice Medical Director concerning changes in patients’ condition requiring order changes and/or changes in the plan of care.
• Coordinate patient services with other members of the IDG as well as contracted services, when needed.
• Submit complete, accurate and relevant clinical notes in a timely manner.
• Submit patient visit schedule weekly.
• Participate in IDG and case conferences.
• Discuss with the supervisor if IDG determines that the patient would benefit from contracted services.
• Take responsibility for ensuring patients’ plans of care are kept current.
• Performs on-call duties (including holidays) per policy and agency need.
• Actively participates in QAPI meetings and activities.
• Participate in staff development meeting.
• Continually strive to improve his/her nursing care skills by attending in-service education, through formal education, attendance at workshops, conferences, active participation in professional and related organizations and/or individual research and reading.
• Provide education to patients/family members regarding the dying process, plan of care and offers guidance with healthcare decisions.
• Provide dietary counseling, taking into account health issues and dietary changes at the end of life.
• Perform death visit per agency’s policy.
• Participate in the patient’s discharge planning process.
• Maintain an on-going knowledge of current drug therapy.
• Adhere to Federal, state and accreditation requirements including Medicare and Medicaid regulations.
• May be requested by a supervisor to fill in for the other nurses.
• Conduct an initial as well as ongoing comprehensive assessments of the patients.
• Obtain a medical history from the patient and/or a family member particularly as it relates to the present condition.
• Conduct a physical examination of the patient, including vital signs, physical assessment, mental status, appetite and type of diet, etc.
• Evaluate the patient, family member(s) and home situation to determine what health teaching will be required.
• Evaluate the patient's environment to determine what assistance will be available from family members in caring for the patient and what services may be needed.
• Be competent in knowledge about different levels of care and when it’s appropriate to offer them.
• Explain nursing and other Agency services to patients and families as a part of planning for care.
• Develop and implement the initial plan of care and work with other members of the IDG in completing and maintaining the comprehensive plan of care.
• Nursing services, treatments and preventative procedures requiring substantial specialized skill and ordered by the physician.
• Observing signs and symptoms and reporting to the physician reactions to treatments, including drugs, as well as changes in the patient's physical or emotional condition.
• Supervise and evaluate the care given by the Hospice Aide at a minimum of once every 14 days and as needed.
• Chart those services rendered to the patient by the staff nurse and changes that have been noted in the patient's condition and/or family and home situation, makes revisions in the nursing care plan as needed, records supervisory visits conducted with the Hospice Aide, evaluates patient care and progress and closes charts of discharged patients.
• Evaluate the effectiveness of her nursing service to the individual and family.
• Discuss with the supervisor problems concerning the patients and possible resolution.
• Provide guidance and supervision to the LPN and supervises the LPN a minimum of every 30 days.
• Cooperate with other agencies providing nursing or related services to provide continuity of care and to implement a comprehensive care plan.
• Participate in staff development meetings.
• Prepare the care plan for the Hospice Aide.

Qualifications

1. Must be a graduate from an accredited School of Nursing.

2. Must be licensed in the State of Massachusetts.

3. One year of RN experience. Hospice experience preferred.

4. Must have excellent assessment skills and problem solving skills.

5. Should be skillful in organization and in the principles of time management and have knowledge of case management processes.

6. Must be a licensed driver with an insured automobile in good working order.

7. The ability to communicate well, both verbally and in writing.

8. Must have no exceptions to RN license, and be able to administer pharmaceuticals, perform medication reconciliation, and any nursing procedures or special treatments needed within the scope of nursing practice for state. All skills to be competencies before actual hands on patient care, and when procedures or treatments are not usually performed.