RN, Care Coordinator- Team - Hope Healthcare-Patient Homes

Job Profile Summary

Role: RN, Case Manager is responsible for assessing and identifying patient/family needs, utilizing the nursing process, coordinating the Plan of Care with the Interdisciplinary Team (IDT), and providing clinical, palliative and supportive care to the patient/family unit in order to keep the participant in their home environment as long as possible.

Qualifications:

• Current license as RN in the state where the employee will be working
• Minimum of one (1) year nursing experience; hospice or hospital experience preferred
• Employees working at PACE, certification of completion of Alzheimer’s Disease and Related Dementias Training through the Florida Department of Elder Affairs
• Previous experience working with an EMR/EHR system
• Mobile Driver – Valid driver’s license and automobile insurance per Company policy
• Reliable transportation to meet visit schedule
• Ability to use equipment with visual and auditory mechanisms
• Ability to effectively communicate in English (verbal and written)
• Ability to visit participant in their homes for assessments
• Ability to perform the essential functions and physical requirements (including, but not limited to: lifting patients and/or equipment, bending, pushing/pulling, kneeling) of the job with or without reasonable accommodation
• Active BLS for healthcare professionals from the American Heart Association or Red Cross

Some locations may require:

• Provides reassurance on the phone to patients and families; assists in finding solutions to their questions and/or recognizes the need for an in person visit and coordinates such visit when needed or requested
• Utilizes appropriate support/expert resources or personnel to resolve complex or difficult situations
• Documents patient/family contact information in the EMR and communicates with the Interdisciplinary Team (IDT)
• Completes initial and semi-annual assessment for all Company services including, but not limited to:
• Explains services to patients/families and addresses questions regarding patient needs, fears, physical limitations while putting the patient/family at ease; presents services in an empathetic and compassionate manner
• Provides information to Physicians and other IDT members and initiates Plan of Care to address patient’s immediate needs
• Initiates skilled nursing interventions to enhance prevention, prevent complications, alleviate symptoms and maximize physical and emotional comfort
• Obtains Physician orders
• Completes documentation per Company policy

Acts as the Company representative at assigned facilities while facilitating referrals to all service lines; works closely with referring hospitals, physicians, facilities, patients, families, and the general public.

Communicates frequently with other members of the IDT.

Provides all necessary clinical communication timely using SBAR.

Discusses any potential needs with after-hours staff.

Develops strong relationships with case managers, physicians, etc. at facilities.

• Satisfactorily complete competency requirements for this position.

• Provides and manages direct care to patients and families as part of Interdisciplinary Team (IDT), incorporating psychosocial, spiritual, cultural, physical and biological components, and appropriate nursing intervention and follow-up.
• Coordinates the Plan of Care, ensuring that an individualized Plan of Care is developed that accurately reflects the patient’s evolving needs.
• Educates patient, family, caregivers and other health professionals about disease process and decline, prevention, palliative interventions, caring, dying process and safety practices.
• Participant visit frequency is dependent on risk score/needs to be determined.
• Home visits to assess home safety, medication compliance, nutritional compliance, DME compliance and ability to live safely in the community.
• Reports changes in the patient’s condition to appropriate members of the IDT or other health professionals.
• Participates with the IDT to evaluate hospice referrals/admissions for level of care appropriateness.
• Attends daily IDT collaboration meetings.
• Presents concise and pertinent oral and written reports to IDT; respects and encourages…