Registered Nurse Case Manager, Hospice

Patient Care

• Provides comprehensive case management to hospice patients.
• Completes an initial assessment of patient and family to determine hospice care needs.
• Completes a complete physical assessment and history of current and previous illness(es).
• Admits to appropriate level of service/care.
• Affirms assessments and evaluations by writing and initiating a plan of care.
• Regularly re-evaluates patient and family/caregiver needs and revises the plan of care as necessary.
• Uses health assessment data to determine nursing diagnosis.
• Develops a plan of care pathway that establishes goals, based on nursing diagnosis and incorporates palliative nursing actions.
• Includes the patient and 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 towards self-sufficiency and optional comfort care.
• Knowledge of state, federal, local and accreditation regulations for the delivery of hospice services.
• Accountable for financial resources and eligibility under various third party payor sources, Medicare and Medi-Cal.

Communication

• Completes, maintains and submits accurate and relevant clinical notes regarding patient’s condition and are given.
• Records pain/symptom management changes/outcomes as appropriate.
• Communicates with the physician regarding the patient’s needs and reports any changes in the patient’s condition; obtains/receives physicians orders as required.
• Communicates with community health related persons to coordinate the care plan.
• 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 other hospice Interdisciplinary Team Members.
• 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 Team Members to meet the emotional needs of the patient and family/caregiver.

Additional Duties

• Mets daily average productivity standards set by the agency.
• Participates in on-call and weekend duties as defined by the agency policies.
• Participates in Quality Management activities.
• Ensures that arrangements for equipment and other necessary items and services are available.
• Instructs, supervises and evaluates hospice aide care provided every fourteen days.
• Participates in educational programs to maintain skills and knowledge of current nursing practice.
• Mets daily average productivity standard set by the organization.