Hospice RN Case Manager - FTE

Description

The Hospice Registered Nurse acts as a case manager for assigned case load. She/he is responsible for providing skilled nursing care and teaching to patients and their families in their place of residence. The nurse is responsible for ensuring the physician's orders are carried out on a timely basis. The nurse completes all necessary documentation and participates in other activities as assigned.

• Completes comprehensive assessment within 5 days of patient admission.
• Contacts all other disciplines involved in hospice patient’s care with update within 48 hours of admission (or sooner if patient’s condition warrants it) as well as ongoing.
• Confers with at least one other core IDT member to develop POC at the time of admission.
• Ensures there is appropriate follow-up with MD if there are discrepancies with medications or treatment protocols.
• Updates the MD with changes in patient’s condition and provides a status report to M.D. at least every 14 days.
• Notifies other members of the IDT of hospice death by the next business day at 9AM unless there are special circumstances.
• Implements hospice POC. Updates POC on regular, ongoing basis to reflect current care.
• Exhibits sound nursing judgment which positively affects individual patient outcomes.
• Implements new physician orders timely and accurately.
• Assesses for, provides and documents patient and family teaching related to patient’s health situation on an ongoing basis (i.e., medications, disease processes, treatments, etc.) and provides written teaching information as appropriate.
• Ensures Clinical Coordinator is notified if call is placed to physician with update, in case there are call-backs and office staff follow-up is necessary.
• Updates Hospice Manager regarding status of patients on regular basis, including a consultation for any unusual circumstances. Assesses for, provides, and documents staff teaching related to patient care on an ongoing basis when patient resides in a facility.
• Completes comprehensive assessment for hospice admits. Assessment requires minimal corrections by supervisor when reviewed.
• Documents towards patient goals at each visit.
• Completes required hospice recertification paperwork within specified time periods.
• Supervises home health aide at least every two weeks and documents supervision.
• Documents coordination of care of assigned case load with all other disciplines involved in patient’s care weekly.
• Develops accurate and individualized POC at the time of admission and ongoing.
• Ensures medication profile is complete (i.e., “new” vs. “changed”, “covered vs. “non-covered”, start and stop dates, all coumadin doses, IV meds, reason for prn meds, etc.) and consistent with physician’s orders. Protocol for initiating standing orders is followed.
• Documents evidence of updates to physician for patients whenever there is a change in status, and minimally every 14 days.
• Ensures all documentation to be included in the medical record is completed within 24 hours of visit.
• Ensures all documentation included in the medical record is thorough, complete and accurate, requiring minimal corrections from supervisor when reviewed.
• Develops initial hospice POC within 24 hours of admission.
• Ensures all hospice admission paperwork is completed and turned in within 12 hours of admit unless there are special circumstances.
• Develops ongoing hospice POC within 5 days of admission.
• Updates hospice POC whenever there are changes in care and minimally every 14 days after the initial POC and no later than by 12N the day before IDT.
• Ensures that all hospice documents are locked at the time of completion.
• Completes hospice discharge summaries within one week of discharge or death.
• Completes medical supply worksheets timely and accurately.
• Completes payroll paperwork timely and accurately.
• Completes visit schedule by 3:30PM each Thursday for the following week and updates schedule as it changes.
• Documents evidence of coordination and collaboration when patient resides in a facility.
• Determines frequency of visits for patients and receives minimal recommendations for changes from supervisor when reviewed.
• Develops and updates patient…