What are the responsibilities and job description for the Hospice RN Case Manager position at Trinity Health At Home?
Day 1 benefits - $10,000 sign on bonus
Provide one-to-one, compassionate care and love your job
Above and Beyond Monticello provides compassionate, exceptional care where people are most comfortable: at home. We are the area's most comprehensive home care provider with trusted quality of care. With new strategy, vision and technology, we are growing and shaping the future of healthcare!
We have a pioneering care model with Home Care Connect, our integrated virtual care program that helps patients avoid preventable ER visits and hospitalizations. It enhances our clinical excellence with advanced, easy-to-use remote monitoring technology and 24/7 access to our Virtual Care Center RNs.
Hospice RN Case Manager
Provides professional nursing care to the organization’s hospice clients as prescribed by the physician, and/or requested by the client/family, and in compliance with the state’s Nurse Practice Act, any applicable licensure/certification requirements, and the organization’s policies and procedures. The RN is fully responsible for the client assessment, care planning, therapeutic intervention, and overall supervision of client care and outcomes, is designated as the case manager for hospice patients. The Hospice RN in collaboration with the physician and other Hospice team members anticipates and manages patient’s symptoms, assists in identifying pt/family/caregiver grief/loss issues and assists in implementing the Hospice plan of care. Provides functional support to Hospice Aides and LPN/LVNs as needed.
Essential Functions
Maintains a current working knowledge of applicable Federal. State and local laws and regulations, the Organizational Integrity Program, Code of Ethics, as well as agency policies and procedures and adheres in a manner that reflects honest, ethical and professional behavior.
Informs the client/caregiver about the agency, care/services available, client obligation for payment, and other responsibilities and rights, before care is initiated. Accurately explains/understands the Hospice Benefit.
Develops and implements an individualized Plan of Care that incorporates realistic, and attainable goals that is also outcome-focused so that the services provided will improve the patient’s quality of life and promote dignity.
Makes appropriate referrals for evaluation/care to other disciplines and services, and coordinates care with others to ensure effective and efficient care is provided.
Utilizes interview, observation and evaluation in assessing clients and applies nursing judgment, consistent with practice standards, in formulating nursing interventions and making recommendations to the physician, client/family and IDT/IDG.
Reports changes in client condition as appropriate and in a timely manner, to the client’s physician and/or Case Manager/designee, and obtains orders for changes in the plan of treatment to respond to the client’s condition.
Re-evaluates and updates patient’s plan of care based on patient goals and progress towards outcomes.
Assess patient and family learning styles and needs for teaching regarding disease process, self-care, end of life care, and dealing with ethical concerns as well as patient goals as part of plan of care.
Responds appropriately to changes in patient’s physical, psychological, or spiritual conditions
Models teamwork to accomplish to accomplish organizational goals and provide quality patient care.
Demonstrates respect for cultural diversity in all care delivery and communication with co-workers, patients, and families.
Maintains and enhances knowledge of pain and symptom management in hospice and palliative care patients, utilizing evidence-based protocols and standing guidelines per policy.
Adequately prepares patients and families regarding the expected disease process
Provides anticipatory education and guidance to patients and families regarding the death and dying process.
Accurately documents observations, interventions and evaluations pertaining to client care management and services in accordance with agency policy and procedure utilizing the point of care information system. This will include assessments, visit reports, medication information, treatments, and coordination of services, client progress or lack of progress toward goals, and contacts with physicians and agency and community providers.
Takes appropriate steps to assure timely submission of client data to the office for inclusion in the client record (by timely electronic transmission of data, or when appropriate by fax or mail).
Documentation reflects progress towards patient/family goals
Documents all collaborative contact with physicians and other members of IDT/IDG team.
Assures that documentation and orders are up to date and completed in a timely manner.
Documents and completes updates and recertification's for patients as required.
Works with scheduling to assure visits and client care coverage are scheduled in accordance with the plan of care, maintains an appropriate productivity level and are suitably assigned to other team members when needed. (Weekly schedule, sup visits, weekend & on-call)
Maintains confidentiality and applies HIPPA standards with all patients.
Promotes a collaborative team atmosphere, and team cohesiveness/functioning
Actively participates in case conference/IDT/IDG with other members of the hospice team. Has IDT/IDG notes prepared on time according to agency policy.
Act as a case manager in coordinating client care with other health team members: updating other disciplines regarding changes in the plan of care and the client’s condition when indicated; and coordinating referrals and recertification information with other disciplines and physician(s).
Assures that standards and practices reflect current standards and best practice within area of expertise.
Acts independently and responsibly to perform duties on a consistent basis and in a timely manner.
Demonstrates furthering professional growth through sharing knowledge with others (e.g. presenting at agency and/or community in-services, acting as preceptor to others), and enhancing own knowledge regarding palliative care and end-of-life issues..
When acting as primary nurse/case manager on the case, takes lead responsibility for care plan and case management, assuring appropriate care, supplies, and follow through.
Delegates tasks to appropriate personnel as indicated by skill level and professional standing (e.g. LPN, HPA)
Develops the HPA plan of care and assures the HPA is oriented to the client and care plan.
Makes bi-weekly supervisory visits to the client to assess quality of aide services provided and need for HHA care plan revisions, offering education to the HPA as needed and feedback as appropriate for staff evaluations.
Supervises LPN care and competence monthly or more frequently as needed to accomplish client goals.
Participates in the orientation of new employees, preceptorship of new RNs and the educational process of nursing students as appropriate.
The duties and responsibilities described are not a comprehensive list and additional tasks may be assigned from time to time, as the scope of the job may change as necessitated by business demands
Minimum Qualifications:
Graduate of an approved Nursing education program
Current Registered Nurse licensure in the state of Iowa
Must have one year of professional nursing experience by regulation.
Must have a minimum of one (1) year experience as a professional care nurse.
Home healthcare/hospice experience preferred.
Exhibits strong communication and interpersonal skills, with a special emphasis on grief/loss management.
Must have current Driver’s license and reliable transportation to and from work site.
Ability to consistently demonstrate commitment to the mission and Organizational Code of Ethics, and adhere to the Compliance Program.
Other benefits
Health, dental and vision insurance - day one benefits
Short and long-term disability
403b with matching contribution
Generous paid time off PLUS 7 paid holidays
Mileage reimbursement
Comprehensive orientation
Tuition reimbursement
About Above and Beyond Monticello
Above and Beyond Monticello is a member of Trinity Health At Home, a national home care, palliative care and hospice organization serving communities in twelve states. We rank in the top 25 percent of home care agencies nationally, by HomeCare Elite, which measures quality for home care providers (2017). We are a comprehensive, trusted provider of home care in the sacred place that people call home. A Catholic-based, non-profit organization, we serve patients and their loved ones with home care (skilled nursing, physical/occupational and speech therapy and medical social work) and other home health services. Our legacy serving western Iowa, eastern Nebraska and southeastern South Dakota continues with a pioneering, future-thinking care model. We blend clinical expertise with our exclusive Home Care Connect™ virtual care program to help patients achieve their health goals. We have energizing new vision and strategy. Join us and shape the future of healthcare!
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Our Commitment to Diversity and Inclusion
Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law.
