Hospice Registered Nurse Case Manager

PRIMARY JOB DUTIES
1. Complete the initial, comprehensive, and ongoing assessment of patient and family/caregiver needs and provide direct or supervised nursing services based on a developed plan of care.
2. Develop an individualized plan of care, in collaboration with the hospice interdisciplinary team, patient, and family, based on assessment, identification of needs, and patient and family/caregiver goals and preferences. Incorporate palliative nursing interventions.
3. Communicate with the physician (Attending and Hospice) regarding the patient's needs, response to treatment, and changes in the patient's condition; obtain/receive physician orders as required.

1. Work closely with other members of the IDG, and in cooperation with family/caregiver to provide holistic physical, psychosocial, emotional, and spiritual services, including bereavement support to the patient and family to achieve the highest quality of care.
2. Demonstrates positive interpersonal relations in dealing with all members of the agency.
3. Effectively demonstrates the mission, vision and values of the Agency on a daily basis.
   1.0 45% QUALITY OF WORK

1.1 15%
Utilizing all aspects of the Nursing Process (assessment, planning, implementation, evaluation) with appropriate skill to effectively carry out the Plan of Care for each patient as evidenced by:

• Assessing the patients' and family/caregivers' physical, psychosocial, bereavement, environmental, safety, and developmental needs.
• Implementing the Hospice Plan of Care as prescribed by the physician and in conjunction with the other members of the interdisciplinary group, and revising the Hospice Plan of Care as patients' needs change.
• Providing care to patients and families through the utilization of interventions and evaluation of outcomes of care.
• Managing all aspects of the patient's plan of care, based on the changing needs of the patient and family/caregiver, to anticipate, prevent, treat, and manage pain and other undesirable symptoms through ongoing communication of collected data and assessment findings, and collaborating with other interdisciplinary team members.
• Provide support, instruction, and education of the patient, family and other caregivers who participate in the care of the patient in relation to needs identified on the plan of care, including, but not limited to: disease process and progression, medications, pain, symptoms associated with disease, oxygen safety, hospice philosophy, and care of the terminally ill.

1.2 15%
Effectively and efficiently assists in the care of hospice patients and assists in the coordination of care with the interdisciplinary team.

• Maintains open communication and coordination of care, acting as a liaison between hospice medical provider, patient/family, and hospice team.
• Performs ongoing assessment of the patient based on the Plan of Care and communicates findings to the Hospice Physician and other interdisciplinary team members as appropriate.
• Performs and reports assessment findings of the patient's pain and other undesirable symptoms to the Hospice Physician in a timely manner.
• Maintains an accurate and updated medical record, including all coordination of care notes, on-going assessments, communications with others involved in patient's care, and any other information pertinent to the care of the patient.
• Provides supervision of patients' assigned LPN and CNA, in accordance with Medicare guidelines and agency policy.
• Attends and participates in regularly scheduled interdisciplinary group meetings.
• Ensures that arrangements for equipment and other necessary items and services are available.
• Reports abuse and neglect in accordance with state laws and regulations as well as organization policy and procedure.

1.3 10%
Appropriately communicates information in accordance with agency policies and procedures and discipline specific guidelines.

• Documents nursing assessments, identified problems, measurable goals of care, and limitations to provision of care, care interventions, and response to care in the electronic medical record.
• Documents all patient related visits and phone calls within the EMR and ensures documentation is completed and synchronized after visit completion.
• Completes, maintains, and submits accurate and relevant notes regarding patient's condition and care given. Records pain/symptom management changes/outcomes as appropriate.
• Documents all physician orders received within the EMR.
• Consults and collaborates with the hospice interdisciplinary team and others involved in the patient's care.
• Maintains close contact with the patient's family/caregiver to provide information, support, and continuity of care.
• Maintains collaborative relationships with long-term care facility personnel to support patient care and ensure quality symptom management.

1.4 5%
Contributes to program effectiveness as evidenced by:

• Provides holistic, patient/family-centered care across treatment settings to ensure continuity of care and facilitate attainment of goals of care.
• Provides medication review and reconciliation of medication list within the EMR. Ensures medications necessary to ensure patient comfort are available.
• Maintains a high level of knowledge pertaining to the management of pain and symptoms in the dying process.
• Participates in the provision of 24/7 on-call nursing services.
• Assumes responsibility for personal growth and development and maintain and upgrade professional knowledge and practice skills through attendance and participation in continuing education and in-service classes and completion of required annual training.
• Actively participates in quality assessment performance improvement teams and activities.
  2.0 30% EFFICIENCY AND EFFECTIVENESS:

2.1 20% Organizes and performs work effectively and efficiently as evidenced by:

• Scheduling self to reduce driving time and mileage and utilizing resources to prevent duplicate driving or trips by determining if others are in the area.
• Ordering only supplies that are needed and is conscientious of minimizing on-hand inventory.
• Ensuring Durable Medical Equipment (DME) is ordered in bulk to reduce delivery cost.
• Ensuring provision of medical supplies is limited to only what is needed in the home.
• Assessing and cleaning medical supply care boxes, bags, and electronic devices every month, maintaining appropriate documentation
• Practicing personal cost containment by responsible use of equipment, supplies, and resources.

2.2 10% Maintains and adjusts schedule to enhance team performance as evidenced by:

• Reporting to work on time and returning promptly from errands, breaks, and meals.
• Managing personal work schedule and time off to promote smooth agency operations.
• Assisting other team members to ensure completion of all work assignments.
• Demonstrating flexibility with changing workload/assignments.
• Does not exceed accrued PTO or qualified leave of absence(s).* cannot exceed

3.0 25% TEAM WORK, MISSION, VISION, VALUES:
3.1 25% Demonstrates positive interpersonal relations in dealing with all members of the team (i.e. co-workers, supervisors, physicians, etc.) as evidenced by:

• Responding to all customers in a courteous, sensitive and respectful manner.
• Demonstrating respect for team members.
• Managing stress and personal feelings without a negative impact on the team
• Working collaboratively and cooperating with other departments.
• Completing the review period without any formal disciplinary action.

• Presenting a clean and neat appearance in personal attire and one's work area.
  JOB SPECIFICATIONS

• Education: Graduate of NLN accredited school of nursing and current license to practice professional nursing as a Registered nurse in the state; Bachelor's Degree preferred.

• Licensure / Certifications: Must have current Registered Nurse license in NC, NC drivers license with an automobile that is insured in accordance with state or organization, and a current American Heart Association CPR certification.
• Experience: Minimum of one years' clinical experience required; hospice experience preferred.
• Essential Technical/Motor Skills: Working knowledge of Word, E-mail, typing of 30 wpm, basic technical or medical knowledge of home health billing requirements. Advanced customer service skills to respond with simple answers, etc.
• Interpersonal Skills: Ability to work independently as well as effectively as part of an interdisciplinary team.
• Essential Physical Requirements: Intermittent physical activity including walking, standing, sitting, lifting, and supporting patients
• Essential Mental Abilities: Ability to concentrate with large volumes of paperwork and data entry, handle pressure of deadlines, good judgment, ability to organize and prioritize workload independently. Emotional/mental stability and stamina
• Essential Sensory Requirements: Keen observation skills.
• Exposure to Hazards: May be exposed to virus, disease and infection from patients and specimens in working environment.
• Other - Hours of Work: Monday – Friday, some on-call required in rotation, including weekends and holidays.