Hospice RN case manager

Job Description

Job Description

Responsible for oversight and care management of hospice patients. Responsible for assessments and care planning, symptom management and end-of-life education to patients and caregivers. Work with an interdisciplinary team to provide physical, emotional, and spiritual support.

Essential Job Functions/Responsibilities

Patient Care

- Completes an initial, comprehensive and ongoing assessments 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.
- Assesses and evaluates patient’s status by:

Writing and initiating plan of care
Regularly re-evaluating patient and family/caregiver needs
Participating in revising the plan of care as necessary
- Uses health assessment data to determine nursing diagnosis.
- 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 appropriate preventive and rehabilitative nursing procedures.
- Administers medications and treatments as prescribed by the physician in the physician’s plan of care.
- Counsels the patient and family in meeting nursing and related needs.
- 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 when assigned by Clinical Manager and assumes responsibility to coordinate patient care for assigned caseload.

Communication
- Completes, maintains and submits accurate and relevant clinical notes regarding patient’s condition and care given.
- Records pain/symptom management changes/outcomes as appropriate.
- 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.
- 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 Members to meet the emotional needs of the patient and family/caregiver.
- Attends interdisciplinary group meetings.

Additional Duties
- 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.
- Fulfills the obligation of requested and/or accepted case assignments.
- Actively participates in quality assessment performance improvement teams and activities.