Geriatric & Palliative Care Case Manager Nurse

SUMMARY   

The Geriatric & Palliative Nurse (Geriatric-PC Nurse) serves as the case manager for a geriatric and palliative care population providing primary and chronic care management, primarily coordinating care with the patient and patient caregivers from enrollment through discharge of services. This care delivery may take place via telephone, in-home/facility visits and/or telehealth services. The Geriatric-PC Nurse utilizes the nursing process and Alive’s visit standards to provide safe, supportive and effective care management. Care provided should be within nursing scope of practice and aligned with the patient’s goals, throughout the disease process, including symptom management, education, and psychosocial support which may include appropriately utilizing resources of social work or chaplaincy as needed. Due to the variety of variables that may impact navigation of care for this population, flexibility, organization, and building rapport rapidly with patients and their caregivers is highly valued. The Geriatric-PC Nurse will be accountable for meeting Alive Care Standards and collaborating effectively with Alive team members as appropriate.    

ESSENTIAL DUTIES AND RESPONSIBILITIES   

The Alive CARE Visit Standards

Present a Professional Image

Represents Alive in a positive manner. Takes pride in personal appearance, conforms to Alive standards of dress code, car cleanliness, driving etiquette and appropriately prepared for visits. Presents self to the public in a calm, confident, competent manner.

Provide Excellent Customer Service

Conducts visit in a professional, courteous manner, projecting warmth during interactions with patient & family. Engages in purposeful conversation using appropriate body language and active listening skills

Assess, Plan, Intervene and Educate

Utilizes critical thinking skills and nursing process to holistically assess patient and family, develop and implement a plan of care that aligns with patient’s goals, including utilization of IDT resources. Educate family/caregiver(s) regarding plan of care, interventions, diagnosis and prognosis, medications, use, administration and side effects, how to provide care, use of equipment and supplies and how to contact Alive for assistance 

Document at the point of care

Completes documentation of patient visit same day and documenting accurate reflection of patient’s care; updates plan of care same day or more timely if indicated.

Create a lasting impression

Concludes patient visit by providing encouragement to patient and caregiver(s), ensuring use of emergency phone number (Call Center Number) and anticipatory needs prior to next visit have been met. Engages in active listening and expresses gratitude before leaving home.

Complete post visit follow-up

Concludes entire encounter according to Alive CARE visit standard: follow up messages to team members as needed, synchronize iPad, and spiritual release of the visit.

COMMUNICATION & COLLABORATION

Demonstrates effective communication skills and acts a liaison between Alive and the patient’s primary geriatric - palliative provider or other medical providers involved in the patient’s care.

Communicates and collaborates with providers, medical directors, outside facilities and other health care providers regarding patient assessment and response to plan of care.

Notifies appropriate staff of status changes per Alive procedure and collaborates with team members to assure appropriate, empathetic and effective patient/care giver support and care

Reports unusual and problematic patient/care giver issues to appropriate supervisor, and other IDT members as appropriate

Alive Care Standard – Culture of Excellence

Timely completion of work: performance evaluations, annual competencies, continuing education requirements, contact hours. Appropriate and timely documentation of mileage; accurate and cost-effective medical supply utilization. 

Alive Care Standard – Quality and Compliance Excellence

Assists the organization in achieving excellence in publicly reported quality scores as well as internal measurements of success. Adheres to Joint Commission and State healthcare laws 

Alive Care Standard – Financial and Time Management Excellence

Arrives on time for interdisciplinary team meetings and is financially responsible with Alive resources.

EDUCATION and/or EXPERIENCE

Current nursing license (Registered Nurse or Licensed Practical Nurse), BSN preferred. Knowledge of or willingness to learn serious illness care including hospice and palliative care. Minimum one-year nursing practice or equivalent experience required. Hospice, Palliative Care, Geriatrics, Medical Surgical, or Home Health and/or long-term care preferred. 

CERTIFICATES, LICENSES, REGISTRATIONS

Current Tennessee RN License or compact license. If required to drive to carry out the duties of this position: current driver's license and automobile insurance as required by Tennessee State Law.