Hospice RN Case Manager

Description

The Hospice Registered Nurse case manager is responsible for their assigned case load. She/he is responsible for providing skilled nursing care and teaching to patients and their families in their place of residence. The RN case manager is responsible for ensuring the physician's orders are carried out on a timely basis. The RN case manager ensures timely coordination of care, completes all necessary documentation, and participates in other activities as assigned.

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Completes comprehensive assessment within 5 days of patient admission.
• Contacts all disciplines involved in hospice patient’s care with update immediately following admission and upon notification of death.
• Confers with other core IDT members to develop POC at the time of admission and with changes of condition.
• Responsible for receiving follow up communication/report of assigned patients from visiting RN/LPN.
• Updates the MD with changes in patient’s condition and provides a status report to M.D. at least every 14 days.
• Ensures accurate medication profile by completing medication reconciliation, education, monitoring for appropriateness, side effects, effectiveness, and adherence to medication regimen at each home visit.
• Ensures comfort medications are available at patient care location per facility policy and patient preference.
• Ensures there is appropriate follow-up with MD if there are discrepancies with medications or treatment protocols.
• Create, follow, and revise an individualized plan of care and communicates changes visiting nurses and patient care CIT.
• Uses critical thinking skills which positively affect individual patient outcomes.
• Implements new physician orders timely and accurately.
• Assesses for, provides and documents patient and family teaching related to patient’s
• health situation on an ongoing basis (i.e., medications, disease processes, treatments, etc.) and provides written teaching information as appropriate.
• Updates Hospice Clinical Manager regarding status of patients on regular basis, including a consultation for any unusual circumstances. Assesses for, provides, and documents staff teaching related to patient care on an ongoing basis when patient resides in a facility.
• Completes accurate comprehensive admission assessment for hospice patients.
• Develops accurate and individualized POC at the time of admission and ongoing.
• Documents towards patient plan of care and goals at each visit.
• Completes required hospice recertification paperwork within specified time periods.
• Ensure completion of home health aide supervisory visit at least every 14 days.
• Documents coordination of care of assigned case load with all other disciplines involved in patient’s care weekly.
• Documents evidence of updates to physician for patients whenever there is a change in status, and minimally every 14 days when reviewing the plan of care.
• Updates hospice POC whenever there are changes in condition and prepares update for the patient care CIT.
• Ensures all documentation included in the medical record is thorough, complete and accurate, requiring minimal corrections from supervisor when reviewed.
• Develops appropriate care plans for the patient’s overall condition at the time of admission.
• Ensures all hospice admission documentation is completed at time of admission.
• Develops ongoing hospice POC within 5 days of admission.
• Ensures that all hospice documents/visits are closed at the time of completion.
• Completes hospice discharge summaries at time of death.
• Documents evidence of coordination and collaboration when patient resides in a facility.
• In collaboration with patient care CIT, determines need for other disciplines (aide, PT, OT, ST, SW) or service and notifies staff.
• Continually works to anticipate hospice patient’s needs regarding symptom management, thus minimizing the likelihood of a patient care crisis.
• Meets productivity standards as annually established.

Requirements

Minimum Qualifications

• ADN or BSN
• Two years of home care and/or hospice experience preferred.
• Minimum of two years of clinical experience.
• Current Wisconsin RN license required.
• Current Wisconsin driver's license.
• Able to take on call responsibilities on rotating basis.
• Excellent communication skills.

Knowledge, Skills and Abilities

• High level of attention to detail
• Ability to work autonomously and make independent judgments.
• Ability to manage conflicting priorities and handle multiple tasks/projects concurrently
• Ability to work well as part of a team and independently
• Exhibit excellent written and verbal communication and organizational skills
• Exceptional customer service skills
• Display and promote high standards of ethical conduct and behaviors consistent with organizational standards.
• Proficient in using an electronic medical record for documentation as well as outlook and other software programs.