Hospice RN Case Manager

Job Title: Registered Nurse Reporting to: Director of Patient Care Services (DPCS) Classification: Regular Full-Time The RN Case Manager plans, organizes and directs hospice care and is experienced in nursing, with emphasis on community health education/experience. The RN builds from the resources of the community to plan and direct services to meet the needs of individual and families within their homes and communities. POSITION REQUIREMENTS • Completes an initial, comprehensive and ongoing comprehensive assessment of patient and family to determine hospice needs. Provides a complete physical assessment and history of current and previous illness(es). • Provides professional nursing care by utilizing all elements of nursing process and as defined in the state Nurse Practice Act. • Develops a care plan that establishes goals, based on nursing diagnosis and incorporates palliative nursing actions. Includes the patient and the family in the planning process. • Initiates the plan of care, regularly re-evaluates patient and family/caregiver needs, and makes necessary revisions as status and needs change. • Uses health assessment data to determine nursing diagnosis. • Initiates appropriate preventive and rehabilitative nursing procedures. Administers medications and treatments as prescribed by the physician in the physician’s plan of care. • Completes, maintains and submits accurate and relevant clinical notes regarding patient’s condition and care given. • Provides health care instructions to the patient as appropriate per assessment and plan. • Assists the patient with the activities of daily living and facilitates the patient’s efforts toward self-sufficiency and optional comfort care. • Acts as Case Manager and assumes responsibility to coordinate patient care for assigned caseload. • Communicates with the physician regarding the patient’s needs and reports changes in the patient’s condition; obtains/receives physicians’ orders as required. • Communicates with community health related persons to coordinate the care plan. • Counsels the patient and family in meeting nursing and related needs. Teaches the patient and family/caregiver self-care techniques as appropriate. Provides medication, diet and other instructions as ordered by the physician and recognizes and utilizes opportunities for health counseling with patients and families/caregivers. Works in concert with the interdisciplinary group. • Provides and maintains a safe environment for the patient. • Assists the patient and family/caregiver and other team members in providing continuity of care. • Works in cooperation with the family/caregiver and hospice interdisciplinary group to meet the emotional needs of the patient and family/caregiver. • Attends interdisciplinary group meetings. • Participates in on-call duties as defined by the on-call policy. • Ensures that arrangements for equipment and other necessary items and services are available. • Supervises ancillary personnel and delegates responsibilities when required. • Assumes responsibility for personal growth and development and maintains and upgrades professional knowledge and practice skills through attendance and participation in continuing education and inservice classes. • Actively participates in quality assessment performance improvement teams and activities. PHYSICAL REQUIREMENTS While performing the duties of this job, the staff is frequently required to: be mobile, sit, stand, talk & hear in person or on the phone, do repetitive motions or utilize fingers/hands/wrists for typing documentation; have visual acuity to perform activities such as but not limited to: make patient assessments, operate equipment, transcribe, work on a computer terminal, take measurements. The staff is occasionally required to bend, climb, balance, stoop, kneel, twist/turn, balance, grasp, pinch, push/pull and/or lift/carry weights up to 50 lbs.