Description
JOB TITLE : RN Case Manager
DEPARTMENT : Clinical Services
Working Relationships
REPORTS TO : Team Leader
SUPERVISES : None
INTERPERSONAL RELATIONSHIPS : All comments, actions and behaviors have a direct effect on the public's perception of Hospice Austin. Interactions with patients, family members, physicians, referral sources, visitors, co-workers, etc. must be in a manner that is courteous, respectful, cooperative and professional. This behavior should promote an atmosphere of teamwork and positive relations.
Equipment / Machinery Used
Office equipment, automobile, infusion pump, enteral feed pump, CADD pump, nebulizer, oxygen concentrator and tank, suction equipment.
POSITION SUMMARY : Provides and coordinates nursing care in the home care program.
Duties And Responsibilities
Provides professional nursing care for hospice patients in the homecare setting.
- Performs initial and ongoing assessment of the impact of the terminal diagnosis on the patient's physical, functional, psychosocial, and environmental needs and activities of daily living, including any risk for pathological grief, cultural and spiritual implications, and verbal and non-verbal communication patterns.
- Performs nursing assessments, including vital signs, pain assessment, breath sounds, etc.
- Triages patient care problems
- Initiates appropriate preventive and rehabilitative nursing procedures as needed and facilitates movement to another level of hospice care when needed.
- Develops, maintains and updates individualized plan of care that involves performing specialized nursing skills related to palliative and end-of-life care related to managing discomfort and providing symptom relief.
- Consults with and educates the patient and caregivers (including hospital, alternate living facility or home health staff) regarding disease process, self-care techniques, end of life care, comfort measures, medication use and side effects, and processes for dealing with ethical issues; may provide specialized training to staff and / or caregivers to ensure adequate care provided
- Performs on-going evaluation of patient / family response to care
- Provides psychosocial support to patients and families
- Provides preparation and support for patient's death; pronounces deaths in accordance with state regulation, provides postmortem care, handles body and death event with respect and dignity and in accordance with patient / family / caregiver wishes
- As needed and depending on current caseloads, may be asked to provide nursing care to pediatric patients
- Utilizes proper bag technique in performing nursing visits
- Reports adverse events (complaints, infections, falls) to team leader or quality nurse within 24 hours of obtaining information
- Performs POS documentation and completes / signs all documentation according to agency protocol
- Complies with minimum weekly visit requirements per company protocol
Coordinates nursing, personal and homemaker care hospice patients in the homecare setting
Attends IDT meetings; coordinates patient / family care and services and prioritizes needs with the members of the IDTInforms the physician and other team members of changes in the patient's needs and outcomes of interventionDetermines scope and frequency of services needed based on acuity and patient / family needsCoordinates personal care, DME, and obtaining medications and medical suppliesUses case management approach, referring to other services as needed (e.g. Nutritionist, PT, OT, SLP)Provides supervision of care provided by CNAs and LVNs and homemakers providing services to the patient according to regulatory guidelinesDocuments in a timely manner patient assessments, patient contacts, physician orders, and clinical and progress notes that demonstrate progress towards established goalsEnsures hospital charts (hospitals, long-term care facilities) include documentation after each patient visit as applicableActs as a liaison between patient and physicians, hospital staff, long-term care facility staff, and other care team members to facilitate ongoing clinical careWorks with Hospice Austin and hospital staff, regarding discharge planning, ordering DME, meds, etc.Evaluates own needs for support and self-care, using identified system(s) to meet the needRecognizes and maintains professional boundaries in relationships with patient / family / caregiverAssists in developing and implementing discharge plans with a five-day notice to patientOther duties as assigned.Qualifications
PREFERRED QUALIFICATIONS
1 year previous nursing experience.Essential Functions
Provides nursing care.1.1 Performs initial and ongoing assessment of the impact of the terminal diagnosis on the patient's physical, functional, psychosocial, and environmental needs, activities of daily living, risk for pathological grief, cultural and spiritual implications, and verbal and non-verbal communication patterns.
1.2 Performs nursing assessments, i.e. Vital signs, pain assessment, breath sounds, etc.
1.3 Triages patient care problems.
1.4 Manages discomfort and provides symptom relief.