RN Case Manager - Home Care

Job Summary

The RN Case Manager is a member of the interdisciplinary team who works to meet the physical, medical, psychosocial, emotional, and spiritual needs of hospice patients and families facing terminal illness and bereavement. The RN Case Manager provides coordination of care, ensures continuous assessment of each patient’s and family’s needs, and implements the interdisciplinary plan of care. In addition to providing for the unique needs of each individual patient, the RN Case Manager will work to provide a superior customer service experience to our long‑term care partners.

This position is hands‑on. Must support the Connecticut Hospices vision, mission, and operating principles.

• We provide quality, compassionate, and competent hospice and palliative care.
• We support families with their decision‑making.
• We support families with participation in caring for their loved ones.
• We aid in enhancing the quality of life for all of our patients, for as long as their life lasts.

• Work as a member of the interdisciplinary team to meet the physical, medical, psychosocial, emotional, and spiritual needs of hospice patients and families facing terminal illness and bereavement.
• Provide coordination of care.
• Ensure continuous assessment of each patient’s and family’s needs and implement the interdisciplinary plan of care.
• Specialize in managing Connecticut Hospices patients who reside in skilled nursing or assisted living communities.
• Provide superior customer service for each patient and their unique needs as well as long‑term care partners.
• Have passion for working with elderly individuals and enjoy the long‑term care environment.
• Professionally manage and coordinate the hospice plan of care.
• Assess, plan, implement, and evaluate the ongoing care needs of patients and families and the responses to interventions in collaboration with other disciplines.
• Supervise patient care rendered by licensed practical nurses, home health aides, and volunteers, including orientation, education, and supervisory visits.
• Coordinate the services provided by all disciplines and community services.
• Identify and utilize resources, referrals such as PT, OT, Home Health, Dietary, Pharmacy, Supplies, Home Medical Equipment, and other visits/consults.
• Work closely with staff of long‑term care facilities to ensure coordination of care and meet their expectations, including timely communication, record maintenance, and participation in care coordination meetings.
• Provide education, supervision, and counseling to patients and families regarding patient care needs, using agency education material as appropriate.
• Provide education to patients, families, caregivers, and referral sources.
• Conduct facility/staff in‑servicing on topics related to hospice care at the request of Connecticut Hospice or long‑term care facility.
• Complete documentation at the time of the event and at the location of care unless otherwise directed, and communicate with facility as per procedures after each patient visit.
• Participate in the on‑call rotation and/or provide shifts during non‑business hours such as evenings, weekends, and holidays based upon program‑identified needs.
• Participate in bereavement support.
• Maintain focus on the patient and family experience of care.
• Appropriately handle patient/family/customer complaints with supervisor.
• Participate in training activities internally within Connecticut Hospice and externally as assigned.
• Participate in agency's continuous quality improvement program and assigned IDT meetings.
• Communicate effectively and tactfully with patients, recognizing their age, cultural diversity, needs, abilities, personal preferences, and physical condition.
• Provide nursing that demonstrates competent nursing skills.
• Demonstrates competencies in all skills required for best clinical practice.
• Demonstrate ability to utilize assessment data to address physical and psychosocial needs of patients.
• Demonstrate understanding of nursing process, interpersonal relationships, and dynamics.
• Maintain a positive professional demeanor.
• Work as directed by supervisor.

• Report and take required…