RN Homecare-Case Manager

Summary

Under the direction of the Hospice & Palliative Care Manager and within established organizational and departmental policies and procedures, responsible for performing skilled nursing care to patients/families in accordance with the State Nurse Practice Act and accepted professional standards of practice, federal, state, and local laws and within the guidelines of his/her professional license. The R.N. delivers care to patients as delegated by the R.N. Case Manager (RN/CM) and/or Hospice & Palliative Care RN Coordinator (HPC-RNC).

This position is part of the Massachusetts Nurses Association Bargaining Unit at Cooley Dickinson VNA & Hospice. Must be able to effectively interact appropriately to an individual's intellectual level and physical ability: adolescent, adult, pediatric.

• Provide professional nursing care under the direction of a RN/CM, HPC-RNC or Hospice & Palliative Care Manager.
• Provide skilled nursing visits to patients and families, including informational or evaluation visits, admission visits, re-visits, or discharge visits.
• Participate in the development of the care plan along with other Interdisciplinary Group IDG members.
• Follow the plan of care and carry out interventions established by the R.N. CM.
• Recognize and report changes in patient condition to the RN/CM or CTM as directed.
• Communicate information on a timely basis, consistent with VNA/Hospice policy, and the urgency of the situation.
• Provide care within the scope of clinical practice and level of competency (see competency policy/procedure) including: assessment of patient status, physical, psychosocial, and environmental; medication monitoring and administration; patient/family teaching; emergency intervention.
• Perform skilled nursing services in homes, skilled nursing facilities, hospital, and other community settings.
• Provide on-call support for patients based on needs and policy of VNA/Hospice. Rotate to weekends, evenings and holidays to maintain adequate staffing.
• Supervise applicable home care team members. Perform in home supervision of Home/Hospice Care Aides according to agency policy.
• Consistently demonstrate competency with nursing skills according to the legal scope of practice and VNA/Hospice policies and procedures.
• Communicate effectively and in accordance with agency requirements.
• Report significant changes in patient status to the RN/CM or CTM in a timely manner consistent with patient needs.
• Maintain accurate clinical records showing interventions, responses and evaluations.
• Document legibly and according to agency documentation guidelines and standards.
• Promote personal safety and a safe environment for patients, families and team members.
• Demonstrate knowledge of safety and infection control practices by compliance with agency policies and procedures.
• Maintain established agency and departmental environmental standards.
• Recognize and respond appropriately to potentially unsafe situations.
• Demonstrate safe and competent practice in the use of equipment.
• Assess safety of environment and take initiative to prevent accidents and promote safety.
• Participate in all mandatory safety education per VNA/Hospice policy.
• Perform job in compliance with VNA/Hospice policies and procedures, objectives and professional standards.
• Accept responsibility for professional nursing role.
• Follow applicable state and federal laws and agency.
• Meet all visit productivity standards established by VNA/Hospice.
• Attend all meetings as required.
• Maintain confidentiality in all aspects of the job. Refrain from discussing patient or staff identities, conditions, or circumstances in public or with other patients.
• Participate in the VNA/Hospice Quality Improvement Program and pertinent activities.
• Practice nursing with respect for individual, cultural and spiritual differences.
• Participate in ongoing, professional self-development.
• Participate in all mandatory education per VNA/Hospice guidelines.
• Evaluate own performance.
• Assume responsibility to keep informed of current changes and trends in hospice / home care nursing including regulations and reimbursement requirements.
• Demonstrate competency in areas of assignment or identify the need for additional training (e.g. pediatric, infusion therapy, specialized equipment).
• Maintain any certifications required for the VNA/Hospice per diem RN position.
• Maintain established agency, hospital and departmental policies and procedures, objectives, confidentiality, quality improvement program, compliance, safety, infection control and environmental standards.
• Maintain professional growth and development through attendance at seminars, workshops, conferences or in-services, professional affiliations or journals to stay abreast of current trends in field of expertise.
• Meet annual competency and retraining requirements.
• Attend meetings as required.

Other Certificate/Diploma Nursing required or Bachelor's Degree Nursing preferred

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