RN Case Manager

GENERAL DESCRIPTION SUMMARY   The Registered Nurse (RN) Case Manager provides, coordinates, teaches and supervises the nursing care of Hospice patients and families/caregivers. Working in collaboration with other members of the interdisciplinary team/group, the RN Case Manager plans and manages the nursing component of the hospice caseload.  The RN Case Manager makes initial and ongoing nursing assessments, judgments and treatment decisions based on patient and family/caregiver needs and wishes and in accordance with her/his professional skills.  Essential Duties & Responsibilities - Within the philosophy, objectives and policies of Capital Caring Health, carries out the following essential functions:   Quality Provision of Services:       1. Assesses, initially and ongoing, the impact of the terminal diagnosis on the patient’s physical, functional, psychosocial and environmental needs and activities of daily living, including:   a. risk for pathological grief  b. cultural and spiritual implications  c. verbal and non-verbal communications patterns.    2. Assesses the ability of the caregiver to meet the patient’s immediate needs.     3. Uses the nursing process to meet the needs of the patient and family/caregiver. Develops, implements and evaluates the individual physician’s plan of care (PPOC) and plan of care (POC) with the patient/family/caregiver and the other members of the IDT/G in the home or as consultant in contract facilities. Manages discomfort and provides symptom relief and apply specialized nursing skills related to palliative and end of life care.  Determines the scope and frequency of services needed based on acuity and patient/family needs.   4. In collaboration with the clinical supervisor and regional general manager, identifies the need for and assigns registered nurses, licensed practical nurses, certified nursing assistants and other nursing support staff to individual patients in order to insure patient care needs are appropriately met.    5. Functions as a member of the IDT/G. Coordinates all patient/family services and prioritization of needs with the members of the IDT/G.  Reports changes in the patient's medical or mental condition to other team members including clinical supervisor, attending physician, on-call staff and agency employees and contractors involved in the patient's care.  Actively participates in coordination of all aspects of patient’s care, in accordance with current professional standards and practice.  Participates in IDT/D conferences to discuss, evaluate and update the plan of care.  6. Revises the IDT/G Plan of Care as needed based on input from patient/family/caregiver, primary physician and other members of the IDT/G, every 14 days.  7. Immediately notifies the attending physician of any changes in the patient’s condition which would indicate a need to alter the plan of care or to terminate the service.    8. Demonstrates flexibility in work schedules and shared responsibility for delivery of care.  Participates in the on-call system as required and/or as assigned by clinical managers to meet after-hours care need.  9. Assumes responsibility for own professional growth and development in order to maintain and improve competence.    10. Evaluates own needs for support and uses identified system(s) to meet the need.   11. Develops new skills by participating in ongoing education and maintaining knowledge of current nursing practice through journals, literature review, etc.  12. Participates in quality improvement activities, QUAPI program and hospice sponsored in-service training.   Serves on committees or teams as approved by the clinical supervisor.    Organizational/Regulatory Compliance:  Applies specific criteria for admission and re-certification to hospice care to establish appropriate level of care and the patient’s eligibility.   Assures that contractors conduct supervisory visits when agencies deliver care by nurses and CNAs.  If hospice contracts with individuals to deliver nurse or CNA services, Capital Caring Health RN shall complete in-home visits.  Initiates preventive and rehabilitative nursing procedures to maximize quality of life.  Delivers or supervises the delivery of skilled nursing services as outlined in the IDT Plan of Care with focus on palliative, preventive and rehabilitative nursing care, according to Capital Caring Health policies and procedures and within the guidelines of the jurisdiction.     Completes medication monitoring, which includes: obtaining medication order, transcribing, preparing and administering medications, and monitoring medication side effects.  Completes all required documentation in a timely manner as required by regulatory standards and as indicated below.  (“Any signed and dated progress notes by each individual delivering service shall be written on the day the service is delivered.”  (Commonwealth of Virginia Regulation; Capital Caring Health standard of best practice):   Initiates the patient's plan of care in accordance with nursing needs specified in the approved plan of treatment and in collaboration with patient/family/caregiver, primary physician and other members of the interdisciplinary team.  Identifies problems, goals and interventions.  Documents in the medical records to meet standard within 24 hours. Maintains communication with the patient/family/caregiver, physician, clinical manager, Patient Accounts, team assistant, on-call staff, insurance case managers, vendors/agencies and other members of the interdisciplinary team as needed to ensure the procurement of services and supplies necessary to implement the plan of care.  Using appropriate forms/formats according to Capital Caring Health policies and procedures, documents above information in the medical record to meet the standard of within 24 hours. Initiates appropriate referrals to other disciplines and/or community resources.  Documents interventions in the medical record to meet the standard of within 24 hours. Prepares and coordinates clinical, progress notes and assessment forms on nursing services delivered in order to document care into the medical record.  Assures completion of Medical Records within the standard of within 24 hours. Teaches and supervises the teaching of family/household members/caregivers/persons who are responsible for assisting the patient with his/her nursing or personal care needs to empower them to meet the patient's needs.  Documents in the medical record within the standard of within 24 hours. Completes discharge/death checklist and discharge/death summary within the standard of 24 hours.Completes all nursing competencies as identified.  People/Communications:    1. Contributes to patient and family counseling and education.  Consults with and educates the patient/family regarding   the disease processes self-care techniques end of life care  the processes for dealing with issues of ethical concern  2. Participates in marketing/education activities in facilities as requested.    Financial Stewardship  Achieves expected productivity standard as defined by the organization and in alignment with best practices in Capital Caring Health’s Hospice Model.

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