Registered Nurse Case Manager RN Home Health andor Hospice

Job Description Summary

The registered nurse plans, organizes and directs hospice care 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 individual and families within their homes and communities.

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 :

A. Writing and initiating plan of care

B. Regularly re-evaluating patient and family / caregiver needs

C. 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 Supervisor / Nursing Supervisor 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