RN Case Manager

Position Summary

The hospice RN provides comprehensive, professional nursing care to patients in both home‑care and assigned facility settings, including conducting admissions visits for new patients and delivering ongoing education to facility staff. The role includes performing thorough initial and ongoing assessments, developing and updating individualized plans of care, managing symptoms, and offering psychosocial and end‑of‑life support to patients and families. The nurse consults with and educates caregivers and facility partners on disease processes, comfort measures, and hospice philosophy, ensuring consistent, high‑quality care across settings. Using a case‑management approach, the RN coordinates all aspects of patient care such as bath aide services, DME, medications, and interdisciplinary referrals while maintaining timely, accurate documentation in both agency and facility records. The nurse collaborates closely with physicians, interdisciplinary team (IDT) members, hospital and facility staff, and other care partners to communicate changes in condition, support discharge planning, and facilitate smooth transitions of care. The role includes supervising CNAs, LVNs, and homemakers, maintaining professional boundaries, and practicing effective self‑care to sustain high‑quality clinical performance.

Essential Functions

• Provides professional nursing care for hospice patients in the home‑care and assigned facility settings.
• Performs initial and ongoing assessment of the impact of the terminal diagnosis on the patient’s physical, functional, psychosocial, and environmental needs, including risk for pathological grief, cultural and spiritual implications, and communication patterns.
• Conducts comprehensive nursing assessments, including vital signs, pain assessment, breath sounds, and other clinically indicated evaluations.
• Triages patient‑care concerns and determines appropriate interventions.
• Initiates preventive, comfort‑focused, and rehabilitative nursing procedures as needed and facilitates transition to another level of hospice care when appropriate.
• Develops, maintains, and updates individualized plans of care, performing specialized nursing skills related to palliative and end‑of‑life care, symptom management, and comfort measures.
• Consults with and educates patients, caregivers, and facility staff regarding disease processes, self‑care techniques, end‑of‑life care, comfort measures, medication use and side effects, and ethical considerations.
• Provides specialized training to staff and/or caregivers to ensure safe and adequate care.
• Performs ongoing evaluation of patient and family response to care and adjusts interventions accordingly.
• Provides psychosocial support to patients and families throughout the course of care.
• Prepares for and supports the patient’s death; pronounces death in accordance with state regulations, provides post‑mortem care, and handles the body and death event with respect, dignity, and according to patient/family wishes.
• May provide nursing care to pediatric patients as needed, depending on caseload.
• Utilizes proper infection control and bag technique during all in‑person visits.
• Reports adverse events (complaints, infections, falls) to the Team Leader or Quality Department within 24 hours of obtaining information.
• Performs point‑of‑service documentation and completes/signs all documentation according to agency protocol.
• Complies with minimum weekly visit requirements per company protocol.
• Conducts admissions visits for new patients in assigned facilities, completing initial comprehensive assessments, initiating the plan of care, and ensuring a smooth transition onto hospice services.
• Provides ongoing education in assigned facilities, including training for facility staff on hospice philosophy, symptom management, communication expectations, and care‑coordination processes.
• Coordinates nursing, personal, and homemaker care for hospice patients in the home‑care and assigned facility settings.
• Attends IDT meetings; coordinates patient and family care and services, prioritizing needs in collaboration with the interdisciplinary team.
• Informs the physician and other team members of changes in the patient’s condition, needs, and response to interventions.
• Determines the scope, frequency, and type of services needed based on patient acuity and patient/family goals of care.
• Coordinates personal‑care services, durable medical equipment, medications, and medical supplies to ensure timely and appropriate delivery.
• Uses a case‑management approach, referring to other disciplines (e.g., nutritionist, PT, OT, SLP) as needed to support comprehensive care.
• Supervises care delivered by CNAs, LVNs, and homemakers in accordance with regulatory guidelines and agency standards.
• Documents patient assessments, contacts, physician orders, and clinical/progress notes in a timely manner, demonstrating progress toward established goals.
• Ensures hospital and facility charts include documentation after each patient visit, as applicable.
• Acts as a liaison between patients, physicians, hospital staff, long‑term‑care facility staff, and other care‑team members to facilitate ongoing clinical care and effective communication.
• Collaborates with Hospice Austin and hospital/facility staff regarding discharge planning, ordering DME, medications, and coordinating safe transitions of care.
• Evaluates personal needs for support and self‑care, using identified systems and resources to maintain professional well‑being.
• Recognizes and maintains professional boundaries in relationships with patients, families, and caregivers.
• Assists in developing and implementing discharge plans, providing advance notice to the patient and family according to regulatory standards.

Working Relationships

Reports to: Team Leader

Supervises: None (provides supervision of CNAs, LVNs, and homemakers as part of care delivery)

All comments, actions, and behaviors have a direct effect on the public’s perception of Hospice Austin. Interactions with patients, family members, physicians, referral sources, visitors, co‑workers, etc., must be courteous, respectful, cooperative, and professional, promoting an atmosphere of teamwork and positive relations.