Home Health RN Case Manager

POSITION SUMMARY

Performs professional nursing in the home health program providing direct skilled patient care in the home. Provides home health services that reflect the agency’s philosophy and acceptable standards of care.

May include, but are not limited to the following:

• Functions as a member of the Home Health Interdisciplinary Team, following the Plan of Care developed in coordination with the Interdisciplinary Team.
• Assumes primary case management responsibilities for individual patient/family, including:
  • Participation in care plan development, implementation, and revision.
  • Participation in every care conference.
• Provides skilled nursing care including but not limited to physical assessments, pain management, administration/supervision of medication, catheterization, dressing changes, irrigations, venipuncture, intravenous infusions, central line care, diabetic care.
• Teaches and demonstrates basic patient care, use of medications, diagnosis related information and treatments to patient/family members/caregivers/representatives.
• Documents orders received and submits to physician for signature.
• Delegates to unlicensed persons per Oregon state Board of Nursing regulations and regularly supervises the tasks delegated.
• Initiates appropriate preventive and rehabilitative nursing procedures.
• Participates in facility care conferences and in-service programs.
• Completes required documentation (i.e., assessments, care plans, clinical notes, agency tracking forms, etc.) In a timely manner in accordance with agency policies.
• Assigns Home Health/Hospice Aide for eligible patients and supervises care given no less than every 14 days.
• Informs the Clinical Director and/or the Clinical Supervisor of unusual or potentially problematic patient/family issues.
• Communicates regularly with the Clinical Director and/or the Clinical Supervisor and other staff members to review problems or unique issues from caseloads, share professional support, and exchange feedback aimed toward enhancing professional growth.
• Participates in the orientation of new staff members.
• Participates in quarterly record review and quality assurance activities.
• Rotates on-call availability as needed to assist and support patient/family through physical and/or emotional crisis situations 24 hr/day.
• Assists with community education regarding the agency programs as requested.
• Other duties as assigned.

On occasion, the Home Health RN Case Manager may be required to assist in the care of home health patients. Additional Hospice duties are as follows:

• Makes the initial evaluation visit to the patient to determine needs, develop Plan of Treatment and provide nursing services.
• Regularly reevaluates the patient’s nursing needs and revises the Plan of Care as indicated in coordination with the Hospice IDT.
• Pain and symptom assessment and management.

• Exercises supervision of Home Health/Hospice Aides in the performance of duties for patients. Provides written assignment and patient specific teaching for all care to be given and regularly makes supervisory visits to patient’s home in accordance with state and federal regulations.
• Supervises care givers performing delegated tasks assigned by the RN. Regularly reevaluates competency in performing the tasks.

Education, Certification, and Licenses

• Graduate of an approved school of professional nursing.
• Must hold a current unencumbered RN nursing license to practice in Oregon.
• Current BLS care or be able to obtain prior to date of hire.

Experience

• One year of nursing practice in a prior home health, hospice or facility setting is required; 3 years preferred.

Knowledge

• Nursing techniques and procedures.
• Medical terminology.
• Medication use and effects.
• Medical record keeping practices.
• Electronic medical record use.

Ability to

• Interpret orders and carry out instructions while exercising judgment within the scope of the position and established nursing practices.
• Work with limited supervision in an independent setting, while able to recognize situations in which supervision and guidance are required.
• Work with computers/programs and be…