Hospice RN Case Manager

Location

MMH-8 Keynote Drive (10628)

The provision of intermittent nursing service to patients in their homes under a plan of care established in collaboration with the patient's physician and according to agency policy and procedures uses hospice concepts and promotes quality of life for the terminally ill.

Reports directly to the Hospice/Palliative Clinical Supervisor.

Supervision exercised:
Home Care Aides.

Requires full range of motion including handling and lifting patients, manual and finger dexterity, eye‑hand coordination. Requires standing, walking, ascending and descending stairs. Occasionally lifts up to 30 pounds. Requires corrected vision and hearing. Requires working under stressful conditions. Requires some exposure to communicable diseases and/or bodily fluids.

Work performed in patients' homes and in an office environment. Some exposure to communicable diseases, toxic substances, medicinal preparations.

• Admits/readmits patients and provides intermittent nursing service to patients and their families in compliance with agency policies/procedures and state and federal regulations, incorporating a complete physical and psychosocial assessment.
• Develops and implements an appropriate care plan and therapeutic goals with the patient/family.
• Evaluates patient safety on a 24‑hour basis.
• Exercises appropriate clinical judgment in coordination of patient care by all services involved.
• Conducts ongoing evaluation of significant changes in the condition of the patient and of progress toward the therapeutic goals.
• Uses Agency and community consultants/resources as needed.
• Instructs patient/family in procedures or responsibilities they are assuming and optimum wellness practices.
• Plans for the patient's discharge from service.
• Appropriately implements and utilizes the OASIS system.
• Consults with patient/family regarding the process of dealing with issues of ethical concern.
• Documents all services provided in the clinical record in accordance with state and federal regulations and Agency policy.
• Ensures all records are complete, accurate, and done in a timely fashion: admissions within 24 hours of first visit; subsequent visits within 48 hours.
• Obtains physician verbal/written orders and complies with all reporting requirements.
• Participates in coordination of care with physicians and other disciplines as appropriate.
• Manages work assignment effectively and efficiently.
• Reports any cases to the Hospice/Palliative Clinical Supervisor where goals cannot be met or at‑risk situations exist and responds appropriately.
• Remains flexible in daily planning, allowing time for emergencies or unexpected visits.
• Maintains productivity as established by the Agency.
• Utilizes payor sources correctly, reflecting changing levels of care.
• Delegates patient care responsibilities to Home Care Nurse (LPN) as appropriate.
• Participates in the development of the hospice interdisciplinary team care plan.
• Establishes the plan of care to be delegated to the Homemaker/Home Care Aide/Companion, orients and supervises the home care aide in accordance with state and federal regulations and Agency policy.
• Develops an initial written plan of care for the HMK/HCA/Companion and updates this plan as patient's condition warrants but no less often than every 60 days.
• Obtains input from HMK/HCA/Companion regarding patient progress.
• Prepares written performance evaluations of home care aides under supervision.
• Provides supervision of home care aides at a minimum of every two weeks or as required by payor source.
• Attends a minimum of 12 hours of in‑service per year, with at least six hours dealing with aspects of hospice care.
• Participates actively in self‑appraisal and the formation of a plan of self‑development.
• Is knowledgeable of agency policies and procedures and adheres to the Agency Corporate Compliance Plan and HIPAA Privacy Plan as per written agreement.
• Seeks appropriate clinical input to ensure appropriate patient care.
• Projects professional image through attitude and compliance with dress code.
• Is capable of precepting new nurses and students.
• Functions as…