Registered Nurse (RN) Case Manager - Home Health

GENERAL PURPOSE:


Plans, organizes, and directs home care services and is experienced in nursing, with emphasis on community health education/experience. The professional nurse builds from the resources of the community to plan and direct services to meet the needs of individuals and families within their homes and communities. Ensure staff and other support resources are appropriately utilized and a high level of interdisciplinary teamwork is maintained through delegation of duties for both Home Health and Hospice.


QUALIFICATIONS:

• Must hold a current and valid nursing licensure to in the state employed.

• Bachelor's degree with one (1) year of home health and/or hospice care experience preferred.

• One (1) to two (2) years of recent acute care experience in an institutional setting.

• Complies with acceptable professional standards and practice.

• Demonstrates good communication and management skills.

• Demonstrates autonomy, organization, assertiveness, flexibility, and cooperation in performing job responsibilities.

• Must hold a current and valid CPR certification.

• Must be a licensed driver with an automobile that is insured in accordance with state/or Company requirements and is in good working order.

• Must be capable of performing the job functions of this position with or without accommodations.

ESSENTIAL JOB FUNCTIONS:


Patient Care:

• Completes initial and ongoing OASIS assessments of patient and family to determine home care needs Or Initial and ongoing comprehensive assessments of the impact of the terminal disease of the patients physical, functional, psychosocial and environmental needs.
• Provides a complete physical assessment and history of current and previous illness(es).
• Regularly re-evaluates patient nursing needs. Implements/develops/documents the plan of care to ensure quality and continuity of care and recommend revision to the plan, as necessary.
• Initiates the plan of care and makes necessary revisions as patient status and needs change.
• Uses health assessment data to determine nursing diagnosis.
• Develops a plan of care, which establishes goals based on nursing diagnosis and incorporates therapeutic, preventative and rehabilitative nursing actions. Includes the patient and the family in the planning process.
• Initiates appropriate preventative and rehabilitative nursing procedures. Administers medications and treatments as prescribed by the physician.
• Counsels the patient and family in meeting nursing and related needs.
• If applicable, consult with and educate the patient and family regarding disease process, self-care techniques, end-of-life care, nutrition, and dietary needs. Prioritize any needs with the members of the IDG/T. Provide training to other staff as needed.
• Provides health care instructions to the patient as appropriate per assessments and plan of care. Determine scope and frequency of services needed based on acuity and patient/family needs.
• Identifies discharge planning needs as part of the care plan development and implements prior to discharge of the patient.
• Acts as Case Manager when assigned by Clinical Supervisor and assumes responsibility to coordinate patient care for assigned caseload.

Communication

• Prepares clinical notes and updates primary physician when necessary and at least every sixty (60) days.
• Communicates with the physician regarding the patient's needs and reports any changes in the patient's condition; obtains/receives physician's orders as required.
• Communicates with community health related persons to coordinate the care plan. Inform physicians and other personnel of changes in the patient's needs and outcomes of intervention.

Additional Duties

• Participate in on-call duties as defined by the on-call policy.
• Ensures that arrangements for equipment and other necessary items and services are available.
• Provides clinical directions to the Aides and LPN/LVN to ensure quality and continuity of service provided.
• Instructs, supervises, and evaluates HH and/or Hospice aide care provided every fourteen (14) days.
• Adhere to all the Company's policies and procedures.
• Perform other duties as assigned.

The above statements are intended to be a representative summary of the major duties and responsibilities performed by incumbents of this job. The incumbents may be requested to perform job-related tasks other than those stated in this description.