RN Case Manager, Homecare

General Summary of Duties: The provision of intermittent nursing service to patients in their homes under a plan of care established in collaboration with the patient’s physician and according to agency policies and procedures.

Supervision Received: Reports directly to a Clinical Manager.

Supervision Exercised: Home Care Aides.

Typical Physical Demands: Requires full range of body motion including handling and lifting patients, manual and finger dexterity, and eye-hand coordination. Requires standing, walking, and the ability to ascend and descend stairs. Requires operation of a motor vehicle. Occasionally lifts and carries items weighing up to 30 pounds. Requires corrected vision and hearing to normal range. Requires working under stressful conditions. Requires some exposure to communicable diseases and/or bodily fluids.

Typical Work Conditions: Work is performed in patients’ homes and in an office environment. Some exposure to communicable diseases, toxic substances, and medicinal preparations.

Essential Duties: (This list may not include all of the duties assigned.)

1. C4, F4 Admits/readmits patients and provides intermittent nursing service to patients and their families in compliance with agency policies and State and Federal Regulations, incorporating the following:

a) A complete physical and psychosocial assessment.

b) Develops and implements an appropriate care plan and therapeutic goals with the patient/family.

c) Evaluation of patient safety on a 24-hour basis.

d) Exercises appropriate clinical judgment in coordination of patient care by all services involved.

e) Ongoing evaluation of significant changes in the condition of the patient and of progress toward the therapeutic goals.

f) Use of Agency and community consultants/resources.

g) Instruction of patient/family in procedures or responsibilities they are assuming and optimum wellness practices.

h) Planning for the patient’s discharge from service.

2. C4, F4 Establishes and maintains case mix weight, utilization, patient satisfaction that aligns with industry standards and agency operational objectives for quality care.

a) OASIS documentation correlates with the Plan of Care.

b) Uses recommended Oasis assessment techniques 100% of the time.

c) OASIS, documentation, and plan of care correlate to 95%.

3. C4, F4 Documents all services provided in the clinical record in accordance with State and Federal Regulations and Agency policy:

a) Documentation, including activities and mileage is exported within 36 hours of visit or prior to next scheduled visit.

b) Obtains physician verbal/written orders and complies with all reporting requirements.

c) Participates in coordination of care with physicians and with other disciplines as appropriate.

4. C4, F4 Manages work assignment in effective and efficient manner:

a) Visits all new therapeutic clients within 24 hours of referral unless otherwise specified

by the physician.

b) Reports any cases to the Supervisor of Clinical Services where goals can not be met

or at-risk situations exist and responds appropriately.

c) Remains flexible in daily planning, allowing time for emergencies or unexpected

visits.

d) Maintains productivity as established by the Agency.

e) Utilizes payer sources correctly, reflecting changing levels of care.

f) Delegates patient care responsibilities to Home Care Nurse (LPN) as appropriate.

g) Demonstrates an understanding of the principles of case management.

h) Demonstrates ability to manage cost and quality.

5. C4, F2 Establishes and evaluates the Plan of Care to be delegated to the Home Health Aide, orients and supervises the Home Health Aide in accordance with State and Federal Regulations and Agency policy:

a) Develops written plan of care for the Home Health Aide and updates this plan as patient’s condition warrants; plan of care must be reviewed every 60 days.

b) Obtains input from Home Health Aide regarding patient progress.

c) Prepares written performance evaluations of home care aides under his/her supervision.

d) Provides supervision of home care aides at a minimum of every 14 days or as required by payer source.

6. C3, F1 Develops and maintains sufficient professional skills and credentials to meet the needs of patient care:

a) Attends a minimum of 12 hours of in-service per year to include mandated annual in-services.

b) Participates actively in self-appraisal and the formation of a plan of self-development.

c) Adheres to Agency Corporate Compliance Plan and HIPAA Privacy Plan as per written agreement.

d) Seeks appropriate clinical input to ensure appropriate patient care.

e) Projects professional image through attitude and compliance with dress code.

f) Capable of precepting new nurses and students.

g) Functions as a team member with consideration to all staff.

h) Provides Agency with current copy of professional license.

i) Maintains CPR certification.

Ancillary Duties

1. C3, F1 Performs other duties as necessary to support Agency programs as assigned by the Supervisor of Clinical Services.

a) Agency committees as requested.

b) Flu/special clinics as needed.

c) Elder Wellness Clinics as assigned.

d) Special Agency or community programs during and/or after regular working hours.

2. C4 , F1 Performs other duties as necessary to maintain current Agency personnel policies:

a) Gives adequate time and attention to administrative duties.

b) Abides by Agency weekend/holiday rotation of nurses.

c) May provide back-up for on-call service.

HIPAA and Privacy: Properly direct any complaints and/or grievances as indicated per VNHSC policy. Comply with HIPAA regulations, specifically the Privacy and Security Rules. Protect personal health information (PHI), electronic personal health information (EPHI) and financial information by limiting the use and disclosure of health information and financial information to the minimum amount necessary with only those who must know how to get the job done. Follow the department’s specific policies and procedures to protect health information. Help one another to ensure confidentiality at all times.

Knowledge, Skills, and Requirements: Knowledge of professional nursing theory and practice and the skills to practice and evaluate patient care. Knowledge of Agency policies, regulations and procedures to administer patient care. Knowledge of medical equipment currently used to provide patient care. Knowledge of common safety hazards and precautions to establish a safe work environment. Skill in applying and modifying the principles, methods and techniques of professional nursing to provide ongoing patient care. Skill in identifying patient-related problems and recommending solutions. Skill in documentation in clinical records. Skill in establishing and maintaining effective working relationships with patients, families, physicians, co-workers, and the community. Ability to maintain quality control standards. Ability to react calmly and effectively in emergency situations. Ability to interpret, adapt and apply guidelines and procedures. Ability to communicate clearly. Possess adequate transportation to carry out job requirements. Must show proof of satisfactory automobile insurance with State of CT minimum coverage, recommended amount of $100,000/300,000. Willingness to provide service in any part of Agency geographic area, according to Agency need.

Education: Graduate of an NLN-approved school of nursing, associate or baccalaureate degree program.

Experience: One (1) year of recent medical/surgical nursing experience, additional experience in community health nursing preferred.

Certificate/License: Possession of a current license to practice as a Registered Nurse in the State of Connecticut.