RN Case Manager Home Team North Austin

Duties and Responsibilities

• Provides professional nursing care for hospice patients in the homecare setting.
• Performs initial and ongoing assessment of the impact of the terminal diagnosis on the patient's physical, functional, psychosocial, and environmental needs and activities of daily living, including any risk for pathological grief, cultural and spiritual implications, and verbal and non-verbal communication patterns.
• Performs nursing assessments, including vital signs, pain assessment, breath sounds, etc. Triages patient care problems.
• Initiates appropriate preventive and rehabilitative nursing procedures as needed and facilitates movement to another level of hospice care when needed.
• Develops, maintains and updates individualized plan of care that involves performing specialized nursing skills related to palliative and end-of-life care related to managing discomfort and providing symptom relief.
• Consults with and educates the patient and caregivers (including hospital, alternate living facility or home health staff) regarding disease process, self-care techniques, end of life care, comfort measures, medication use and side effects, and processes for dealing with ethical issues; may provide specialized training to staff and/or caregivers to ensure adequate care provided.
• Provides psychosocial support to patients and families.
• Prepares and supports the patient’s death; pronounces deaths in accordance with state regulation, provides postmortem care, handles body and death event with respect and dignity and in accordance with patient/family/caregiver wishes.
• May be asked to provide nursing care to pediatric patients.
• Utilizes proper bag technique in performing nursing visits.
• Reports adverse events (complaints, infections, falls) to team leader or quality nurse within 24 hours of obtaining information.
• Performs POS documentation and completes/signs all documentation according to agency protocol.
• Complies with minimum weekly visit requirements per company protocol.
• Captures and coordinates nursing, personal and homemaker care hospice patients in the homecare setting.
• Attends IDT meetings; coordinates patient/family care and services and prioritizes needs with the members of the IDT.
• Informs the physician and other team members of changes in the patient's needs and outcomes of intervention.
• Determines scope and frequency of services needed based on acuity and patient/family needs.
• Captures and coordinates personal care, DME, and obtaining medications and medical supplies.
• Uses case management approach, referring to other services as needed (e.g. Nutritionist, PT, OT, SLP).
• Provides supervision of care provided by CNAs and LVNs and homemakers providing services to the patient according to regulatory guidelines.
• Documents in a timely manner patient assessments, patient contacts, physician orders, and clinical and progress notes that demonstrate progress towards established goals.
• Ensures hospital charts (hospitals, long-term care facilities) include documentation after each patient visit as applicable.
• Acts as a liaison between patient and physicians, hospital staff, long-term care facility staff, and other care team members to facilitate ongoing clinical care.
• Works with Hospice Austin and hospital staff, regarding discharge planning, ordering DME, meds, etc.
• Evaluates own needs for support and self-care, using identified system(s) to meet the need.
• Recognizes and maintains professional boundaries in relationships with patient/family/caregiver.
• Aids in the development and implementation of discharge plans with a five-day notice to patient.

Qualifications

• Bachelor’s degree in Nursing from an accredited school of nursing.
• Current Texas RN license.
• Experience in hospice care preferred.
• Knowledge of hospice care principles and practices.
• Ability to communicate effectively with patients, families, and healthcare providers.
• Ability to perform basic first aid and CPR.