RN Case Manager Hospice

About the role

The registered nurse plans, organizes and directs hospice care and is experienced in nursing, with emphasis on community health education/experience. The professional nurse builds from the resources of the community to plan and direct services to meet the needs of individual and families within their homes and communities.

Responsibilities

• 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.
• Assesses and evaluates patient’s status by:
  • Writing and initiating plan of care
  • Regularly re-evaluating patient and family/caregiver needs
  • Participating in revising the plan of care as necessary
  • Initiates the plan of care and makes necessary revisions as patient status and needs change
• 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.
• 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.
• As a mandatory reporter, reports failure to comply with the requirements of VA 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.
• Reports must be submitted immediately when the reporting person has reasonable cause to believe that abandonment, abuse, financial exploitation, or neglect of a vulnerable adult has occurred.
• 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.
• 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.

Qualifications

• Graduate of an accredited school of nursing.
• Registered Nurse, with a License in good standing to practice in the state of Virginia.
• Registered nurses shall have a minimum of (a) one