RN case manager is responsible for identifying and coordinating patient/family care to support terminally ill patients and families in home, skilled nursing facility or residential care facility. Frequency of patient / family contacts will be at the discretion of the Case Manager and his/her assessment of need, but will be a minimum of once per week. The Case Manager endeavors to utilize teaching, assessment, and intervention skills to provide comfort care and maximize the quality of life for the patients and families.
1. Assess home care needs, being aware of the physical, emotional, and spiritual aspects and gather data on social, economic and cultural factors which may influence health, well-being and quality of life.
2. Assist patients, family members or other clients with concern and empathy; respect confidentially and privacy and communicate in a courteous and respectful manner.
3. Provide direct care to patients as prescribed in the Interdisciplinary Plan of Care in order to maintain the highest level of comfort and quality of life and assuming primary responsibility for case management.
4. Evaluate and perform ongoing assessment and revise initial written plan of care with Interdisciplinary collaboration weekly or as the needs and conditions of the patient/family change.
5. Authorize, coordinate and supervise care, as prescribed in the Interdisciplinary Plan of Care, with contracted vendors in order to meet the needs of the patient.
6. Attend and participate in weekly patient care conferences (PCC)
7. Document accurate and ongoing assessment of patient status via a variety of mediums of communication (verbal, written, email, computer documents and databases). Document patient care reflecting nursing interventions, patient response to care, patient needs, problems, capabilities, limitations, and progress toward goals. Documentation includes evidence of appropriate patient/significant other teaching, and the understanding of these instructions is noted in the medical record. Maintain up-to-date charts and records on patient care and regular communication with the patient’s physician regarding changes in the patient’s plan of care.
8. Investigate and follow through on unusual orders or requests for service or information.
9. Perform blood draws if required.
10. Participate in the agency’s on-call rotation as prescribed by the needs of the agency to provide nursing service to clients when required outside office hours.
11. Be available, when possible, to meet a patient/family's need for continuous care in time of crisis.
12. Coordinate community resources and other agency disciplines participating in patient care.
13. Minimize non-productive time and fill slow periods with activities that will enable you to prepare to meet the future needs of the agency.
14. Supervise and maintain ongoing effective communication with other hospice personnel involved with patient care. This may involve formal and informal team meetings in addition to PCC.
15. Knowledge of and availability to perform patient intakes and information visits as needed including explanation of the hospice benefit/Medicare, complete physical assessment, completion of all pertinent paperwork, and communication of new patient status to the VHAZ team.
16. Knowledge and availability to handle patient information calls and overflow of intake/Triage calls.
17. Provide bereavement resources to the family as appropriate.
18. Participate in hospice and community health programs as requested to promote the growth and understanding of the hospice concept.
19. Performs other duties as assigned consistent with skills and training and the mission and goals of the agency.