Hospice Registered Nurse Case Manager

JOB DESCRIPTION SUMMARYThe registered nurse plans, organizes and directs hospice care and is experienced in nursing,with emphasis on community health education/experience. The professional nurse builds fromthe resources of the community to plan and direct services to meet the needs of individual andfamilies within their homes and communities.ESSENTIAL JOB FUNCTIONS/RESPONSIBILITIESPatient Care1. Completes an initial, comprehensive and ongoing comprehensive assessment of patientand family to determine hospice needs. Provides a complete physical assessment andhistory of current and previous illness(es).2. Provides professional nursing care by utilizing all elements of nursing process and asdefined in the state Nurse Practice Act.3. Assesses and evaluates patient’s status by:A. Writing and initiating plan of careB. Regularly re-evaluating patient and family/caregiver needsC. Participating in revising the plan of care as necessary4. Initiates the plan of care and makes necessary revisions as patient status and needschange.5. Uses health assessment data to determine nursing diagnosis.6. Develops a care plan that establishes goals, based on nursing diagnosis and incorporatespalliative nursing actions. Includes the patient and the family in the planning process.7. Initiates appropriate preventive and rehabilitative nursing procedures. Administersmedications and treatments as prescribed by the physician in the physician’s plan of care.8. Counsels the patient and family in meeting nursing and related needs.9. Provides health care instructions to the patient as appropriate per assessment and plan.10. Assists the patient with the activities of daily living and facilitates the patient’s efforts towardself-sufficiency and optional comfort care.11. Acts as Case Manager when assigned by Clinical Supervisor and assumes responsibility tocoordinate patient care for assigned caseload.Communication1. Completes, maintains and submits accurate and relevant clinical notes regarding patient’scondition and care given. Records pain/symptom management changes/outcomes asappropriate.2. Communicates with the physician regarding the patient’s needs and reports changes in thepatient’s condition; obtains/receives physicians’ orders as required.3. Communicates with community health related persons to coordinate the care plan.4. Teaches the patient and family/caregiver self-care techniques as appropriate. Providesmedication, diet and other instructions as ordered by the physician and recognizes andutilizes opportunities for health counseling with patients and families/caregivers. Works inconcert with the interdisciplinary group.5. Provides and maintains a safe environment for the patient.6. Assists the patient and family/caregiver and other team members in providing continuity ofcare.7. Works in cooperation with the family/caregiver and hospice interdisciplinary group to meetthe emotional needs of the patient and family/caregiver.8. Attends interdisciplinary group meetings.Additional Duties1. Participates in on-call duties as defined by the on-call policy.2. Ensures that arrangements for equipment and other necessary items and servicesare available.3. Supervises ancillary personnel and delegates responsibilities when required.4. Assumes responsibility for personal growth and development and maintains and upgradesprofessional knowledge and practice skills through attendance and participation incontinuing education and inservice classes.5. Fulfills the obligation of requested and/or accepted case assignments.6. Actively participates in quality assessment performance improvement teams and activities #J-18808-Ljbffr Paycom