RN Case Manager

Scope

• Responsible for providing support to patients, families, and caregivers by triaging calls and making weekend visits to meet patient needs.
• Plan, coordinate, provide and document care for terminally ill patients from day of admission through day of discharge.
• Utilizing physicians’ orders and professional skills, develop and implement a hospice plan that meets each patient’s specific needs and is in compliance with Joint Commission, federal and state regulations, reimbursement guidelines as well as the organization’s policies and procedures.
• The foundation of hospice nursing is a complete skilled assessment, communicating with IDG and patient/family, and following the plan of care to meet the needs of the patient and the family during the terminal process.

Key Responsibilities

• Provide Case Management for Hospice Clients – Admission and ongoing assessments are accurate, and charting is completed in the home. Assist family and client with plan of care and goals to best meet the goals of the patient during the terminal illness process. Perform patient care responsibilities considering needs specific to the standard of care for patient’s age and cultural practices. Address and support cultural practices so long as such practices do not harm others. Provide supervision and oversight of the home health aide. Knowledgeable of current federal, state, and organization regulations concerning patient care.
• Provide Palliative Care and Pain Management – Perform all aspects of patient care in an environment that optimizes patient safety and reduces the likelihood of medical/health care errors. Support and maintain a culture of safety and quality. Demonstrate knowledge of medications and their correct administration based on age of the patient and the patient’s clinical position. Understand the standing orders and provide pain relief and comfort measures per doctor orders. Adequately assess and reassess pain. Utilize appropriate pain management techniques. Educate the patient and family regarding pain management. Ensure patient’s pain and symptoms are controlled. Respond to the physical, mental, social and emotional needs of terminally ill patients and their families. Offer ongoing support and palliative care. The hospice RN is on call and responsible for triaging all calls and providing coverage on weekends, evenings, and holidays.
• Active Member of the IDG – Offer ongoing support and palliative care. Refer patient needs appropriately to ancillary services available. Perform all aspects of patient care in an environment that optimizes patient safety and reduces the likelihood of medical/ health care errors. Initiate case conferences to discuss multidisciplinary team responsibilities, pain management, bereavement counseling, new problems, etc. Support and maintain a culture of safety and quality. Supervise Hospice Aides on an every-other-week basis.
• Bereavement Care – Actively participate in the bereavement plan for all families and attends hospice community events.
• Other Duties as Assigned – The duties and responsibilities listed above are representative of the nature and level of work assigned and are not necessarily all inclusive.