RN Homecare-Case Manager

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Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.

With energy and purpose, Cooley Dickinson Health Care, a member of the Mass General Brigham system, is advancing health care in western Massachusetts, and has been since 1886. Our network employs more than 2,000 medical professionals and support staff, at our main Hospital campus in Northampton and additional locations in twelve towns throughout the Pioneer Valley. Cooley Dickinson’s VNA & Hospice is also a vital part of our network, providing home-based services throughout Hampshire and Franklin counties.
** Job Summary
** 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.
Essential Functions  
-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…