Hospice RN Case Manager

JOB SUMMARY

The registered nurse plans, organizes and directs hospice care and is experienced in nursing, with emphasis on community health education/experience. The professional nurse builds from the resources of the community to plan and direct services to meet the needs of individual and families within their homes and communities.

• Patient Care
  • Completes an initial, comprehensive and ongoing assessments of patient and family to determine hospice needs. Provides a complete physical assessment and history of current and previous illness(es).
  • Provides professional nursing care by utilizing all elements of nursing process.
  • Assesses and evaluates patient’s status by:
    • Writing and initiating plan of care
    • Regularly re-evaluating patient and family/caregiver needs
    • Participating in revising the plan of care as necessary
  • Uses health assessment data to determine nursing diagnosis.
  • Develops a care plan that establishes goals, based on nursing diagnosis and incorporates palliative nursing actions. Includes the patient and the family in the planning process.
  • Initiates appropriate preventive and rehabilitative nursing procedures. Administers medications and treatments as prescribed by the physician in the physician’s plan of care.
  • Counsels the patient and family in meeting nursing and related needs.
  • Provides health care instructions to the patient as appropriate per assessment and plan.
  • Assists the patient with the activities of daily living and facilitates the patient’s efforts toward self‑sufficiency and optional comfort care.
  • Acts as Case Manager and assumes responsibility to coordinate patient care for assigned caseload.
• Communication
  • Completes, maintains and submits accurate and relevant clinical notes regarding patient’s condition and care given. Records pain/symptom management changes/outcomes as appropriate.
  • Communicates with the physician regarding the patient’s needs and reports changes in the patient’s condition; obtains/receives physicians’ orders as required.
  • Communicates with community health related persons to coordinate the care plan.
  • Teaches the patient and family/caregiver self‑care techniques as appropriate. Provides medication, diet and other instructions as ordered by the physician and recognizes and utilizes opportunities for health counseling with patients and families/caregivers. Works in concert with the interdisciplinary group.
  • Provides and maintains a safe environment for the patient.
  • Assists the patient and family/caregiver and other team members in providing continuity of care.
  • Works in cooperation with the family/caregiver and hospice Interdisciplinary Group Members to meet the emotional needs of the patient and family/caregiver.
  • Attends interdisciplinary group meetings.
• Additional Duties
  • Participates in on‑call duties as defined by the on‑call policy.
  • Ensures that arrangements for equipment and other necessary items and services are available.
  • Supervises ancillary personnel and delegates responsibilities when required.
  • Assumes responsibility for personal growth and development and maintains and upgrades professional knowledge and practice skills through attendance and participation in continuing education and in‑service classes.
  • Fulfills the obligation of requested and/or accepted case assignments.
  • Actively participates in quality assessment performance improvement teams and activities.

• Graduate of National League for Nursing accredited school of nursing.
• Minimum of two years of experience, at least one of which is in the area of public health, home care, or hospice nursing is preferred.
• Management experience not required. Responsible for supervising hospice aides.
• Registered nurse with current licensure to practice professional nursing in the state.
• Demonstrates excellent observation, problem solving, verbal and written communications; nursing skills per competency checklist.
• Shows ability to organize and prioritize workload independently.
• Prolonged or considerable walking or standing. Able to lift, position, and/or transfer patients. Able to lift supplies and equipment. Considerable reaching, stooping, bending,…