Hospice RN Case Manager

Patient Care

• Completes an initial, comprehensive and ongoing comprehensive assessment of patient and family to determine hospice needs.
• Provides a complete physical assessment and history of current and previous illness(es).
• Provides professional nursing care by utilizing all elements of nursing process.
• Achieves regular re-evaluation of patient and family/caregiver needs.
• Initiates and revises the plan of care as necessary.
• Uses health assessment data to determine nursing diagnosis.
• Develops a care plan that establishes goals, based on nursing diagnosis and incorporates palliative nursing actions.
• Includes the patient and the family in the planning process.
• Initiates appropriate preventive and rehabilitative nursing procedures.
• Administers medications and treatments as prescribed by the physician in the physician’s plan of care.
• Counsels the patient and family in meeting nursing and related needs.
• Provides health care instructions to the patient as appropriate per assessment and plan.
• Assists the patient with the activities of daily living and facilitates the patient’s efforts toward self-sufficiency and optional comfort care.

Communication

• Completes, maintains and submits accurate and relevant clinical notes regarding patient’s condition and care given.
• Records pain/symptom management changes/outcomes as appropriate.
• Communicates with the physician regarding the patient’s needs and reports changes in the patient’s condition; obtains/receives physicians’ orders as required.
• Communicates with community health related persons to coordinate the care plan.
• Reports failure to comply with the requirements of MO state, local, and federal law and ethics as required within 14 calendar days, using Dept. of Health forms.
• Reports suspected abandonment, abuse, financial exploitation, or neglect of a person to the department of social and health services and the proper law enforcement agency.
• Teaches the patient and family/caregiver self-care techniques as appropriate.
• Provides medication, diet and other instructions as ordered by the physician and recognizes and utilizes opportunities for health counseling with patients and families/caregivers.
• Works in concert with the interdisciplinary group.
• Provides and maintains a safe environment for the patient.
• Assists the patient and family/caregiver and other team members in providing continuity of care.
• Works in cooperation with the family/caregiver and hospice interdisciplinary group to meet the emotional needs of the patient and family/caregiver.
• Attends interdisciplinary group meetings.

Additional Duties

• Participates in on-call duties as defined by the on-call policy.
• Ensures that arrangements for equipment and other necessary items and services are available.
• Supervises ancillary personnel and delegates responsibilities if required.
• Assumes responsibility for personal growth and development and maintains and upgrades professional knowledge and practice skills through attendance and participation in continuing education and in-service classes.
• Fulfills the obligation of requested and/or accepted case assignments.
• Actively participates in quality assessment performance improvement teams and activities.