RN Patient Care Manager

I. Qualifications

• Registered Nurse from an accredited program currently licensed and in good standing with the Pennsylvania State Board of Nursing, with one year of administrative or supervisory experience in community health programs.
• Must have strong clinical skills with hospice and/or home health experience. Must have excellent verbal and written communication skills, as well as good community relations.
• Must have the ability to motivate and work with fellow employees and volunteers. Must be effective in working with different levels of healthcare providers and able to express the hospice concept to families, patients, physicians, community, volunteers, staff, and other professionals. This position requires planning, supervision, and administration.

II. RESPONSIBILITIES

The Patient Care Manager will be responsible for the coordination of the Interdisciplinary Team. The Patient Care Manager acts as a liaison between the IDT and the Executive Director.

The PCM works in conjunction with the Executive Director to ensure:

A. Admission, Assignment, Supervision of Staff

• Monitor to ensure coordination and follow-through is complete for all referrals to the hospice program.
• Assist the admission team in coordination and assignment of all newly admitted hospice patients to the appropriate team and/or discipline, i.e., admission nurse, case manager, or other RN.
• Work collaboratively with the medical records department to ensure all admission documentation (case sheet, initial assessment, initial plan of care, medication profile, C.N.A. assignment) is completed within a 24-hour period and dispersed among team members.
• Assign a Nurse Case Manager to implement the Plan of Care and oversee the delivery of care to the patient/family.
• Assist the medical records department in monitoring the documentation of all written material related to patient care.
• Act as triage nurse for case managers requiring assistance with symptom management.
• Assist with change in level of care for patients, including locating a facility for placement, ensuring a physician for follow-up at the facility, notification of the primary care physician and medical director, transport, provision of medications, and DME.
• Supervise and evaluate the scheduling of C.N.A.s, contract employees, nurse case managers, visiting nurses, continuous care staff, on-call nurses, and medical directors.
• Ensure communication of all patient admissions and changes in the Plan of Care is appropriately relayed to each member of the Interdisciplinary Team and Primary Care Physician.
• Ensure policies and procedures concerning patient care are followed.
• Ensure and participate in the annual evaluation of Nurse Case Managers, C.N.A.s, and Medical Directors.
• Recruit, hire, and train all clinical staff.
• Provide orientation on symptom management and medication utilization to all nurses and physicians.
• Provide and/or assist in ongoing training of clinical staff.
• Participate in the CQI program.
• Ensure that the highest ethical standards are practiced throughout the organization.
• Monitor the medication profiles for each patient on service to identify formulary and non-formulary utilization.
• Identify ways to reduce local pharmacy utilization and non-formulary medication utilization.
• Participate with medical directors to ensure appropriate and timely evaluation and treatment of all hospice patients.
• Participate in communication with patients and families regarding concerns/frustrations related to services and care.
• Provide continuous support to all clinical staff.

B. Continuous Evaluation of Skilled Nursing Staff and C.N.A.s

• Monitor for and ensure appropriate utilization of “Palliative Pathways” and “Formulary” medications in the care of hospice patients.
• Participate in all IDT meetings in which admissions, certifications, recertifications, and medical management of the patients are discussed.
• Coordinate and present or arrange for in-services specific to clinical staff throughout the year.
• Meet at least quarterly with skilled nursing staff to discuss job-related issues and provide support.
• Meet at least quarterly with C.N.A.s to discuss job-related issues and provide support.
• Participate in and/or assist with formal evaluations annually for clinical members of the Self Care Managed Team (skilled nurses and C.N.A.s).
• Provide annual evaluations for all RNs and LPNs.
• Perform joint visits with case managers and admission nurses at least annually.
• Ensure required supervisory visits are done on a routine basis for all LPNs and C.N.A.s.

C. Ensure Optimum Patient Care by:

• Participating in routine visits and admissions of patients in times of high census or low staff availability.
• Participating in the management of admissions and patient care in times of high census or low staff availability.
• Assisting in staffing or reassigning visits to other team members when a staff member is ill or on vacation.
• Participating in program development, community networking, and community/medical staff education to achieve census building.
• Assisting with the volunteer and bereavement programs.
• Participating in budgetary decisions related to cost-effectiveness and appropriate decision-making by clinical staff, i.e., utilization of pharmaceuticals, DME, and patient care supplies, salary, overtime, etc.
• In the absence of the Administrator, performing administrative duties, as necessary.
• Ensuring adequate supervision when utilizing time off.
• Providing input into Policy and Procedure development, i.e., revisions, program development, and new markets

III. ORIENTATION AND TRAINING

Tender Care Hospice will provide orientation and training, as necessary, to assist the Patient Care Coordinator in performing the responsibilities listed above. Training may be in-house or at outside seminars. Evidence of orientation and training will become part of the personnel file.

IV. ON-CALL

The PCM and trained RNs will have rotating on-call assignments as needed.

V. ACCOUNTABILITY

Reports directly to the Executive Director.