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.
30+ days ago