Registered Nurse Case Manager - Home Care - Fond du Lac & Dodge Counties

Patient Care

• Develops a written plan of care for each patient on caseload
• Updates and initiates the plan of care and assumes responsibility for the ongoing interdisciplinary assessment and development of the individualized plan of care in partnership with the patient, representative (if any), and caregiver(s)
• Affirms patient’s condition, initiates plan of care, re-evaluates and updates as necessary
• Initiates proper preventative and rehabilitative nursing procedures and provides services that are ordered by the physician as indicated in the plan of care
• Provides skilled nursing care
• Provides patient, caregiver, and family counseling
• Provides patient and caregiver education
• Prepares clinical notes
• Communicates with the physician who is responsible for the home health plan of care and other health care practitioners (as appropriate) related to the current home health plan of care
• Obtains all necessary physician orders and collaborates with physician as patient’s needs dictate
• Attends case conferences to discuss multidisciplinary team responsibilities, patient progress, plans for continued care, new problems, etc.
• Re-evaluates the need for continued care on an ongoing basis; initiates recertification as necessary
• Identifies discharge planning needs as part of the care plan development and implements prior to discharge of the patient

Communication

• Prepares clinical notes and updates the primary physician when necessary and at least every sixty days
• Communicates with the physician regarding the patient’s needs and reports any changes in the patient’s condition; obtains/receives physician’s orders as required
• Communicates with community health related persons to coordinate the care plan

Additional Duties

• Participates in the agency’s quality assessment and performance improvement program and home health agency-sponsored in-service training
• Participates in holiday rotation and on-call duties as defined by the on-call policy and agency requirements
• Ensures that arrangements for equipment and other necessary items and services are available
• Instructs, supervises, and evaluates home health aide care and LPN care provided every two (2) weeks per state and agency regulations
• Supervises Licensed Practical Nurses (LPNs), Licensed Vocational Nurses (LVNs), and/or Home Health Aides (HHAs)/Certified Nursing Assistants (CNAs), as directed
• Participates in all mandatory meetings, training, and in-service education
• All weekend/holiday visit documentation must be completed by the following business day by 8:00 AM