Job Summary

The Nurse Case Manager (NCM) is a member of the core interdisciplinary team responsible for the care and case management of patient/families admitted to hospice service. The NCM, in collaboration with pt/family, physician and interdisciplinary team, develops and coordinates an individualized Plan of Care (POC) that reflects pt/family goals related to Safe & Comfortable Dying, Self-Determined Life Closure and Effective Bereavement. The NCM demonstrates sensitivity and compassion for the issues involved with serving patients and families facing a terminal illness, death and bereavement; clinical competence in pain and symptom management; and fiscal responsibility in the planning and delivery of services. The Nurse Case Manager provides direct supervision for Hospice Aides and LVNs, when utilized.

Essential Responsibilities

Patient/family care

• Recognizes the patient and family as the "unit of care" and active members in the development of the POC
• Respects patient right to self-determination and acts as advocate within the context of the values and ethical standards of HSCC. Meets pt/family where they are
• Utilizes nursing process in providing primary care to pt/families
• Documents all care and care planning per agency policy
• Provides nursing interventions for pt/family as ordered by the physician and in accordance with the POC, safe nursing practice and the policies and procedures of HSCC
• Assesses and monitors management of pain and symptoms in collaboration with patient/family, IDG and physician to achieve maximum comfort
• Exercises good clinical judgment
• Administers medications and treatments as ordered prn
• Demonstrates the ability to articulate the parameters of hospice care and services
• Demonstrates the ability to work with pt/families under stress & in crisis
• Develops, manages, reviews & revises HA POC & supervises HA performance per HSCC policies & procedures
• Reviews and considers patient data gathered by LVN/HHA when developing and revising the plan of care.
• Instructs and supports pt/family unit re: symptom mgmt, patient care, disease process & death/dying
• Participates in providing after-hours coverage to pt/family as needed

Case Management

• Visit frequencies are appropriate to patient status
• Plans & provides care within the structure of the Conditions of Participation & the Hospice Medicare/Medi-Cal Benefit
• Collaborates with IDG & Attending Physician to develop, manage, review and revise a written POC that includes identified goals, interventions and outcomes that address pt/family physical, psychosocial and spiritual goals related to Safe & Comfortable Dying, Self-Determined Life Closure and Effective Grieving
• Opens, closes & revises POC per HSCC guidelines
• Documents all contacts/instructions/ interventions per HSCC policies & procedures
• Obtains medications, medical supplies and equipment per pt need/physician order
• Demonstrates understanding of pharmacy-related policies & procedures
• Assess patient's continued appropriateness for hospice care per HSCC Recertification protocols
• Completes Recertification documentation in a timely and accurate manner
• Exercises professional management and coordinates care between and among involved parties in home, SNF and RCFE setting
• Provides concise and timely on call reports
• Submits completed paperwork & time sheets within the timeframes per HSCC policies & procedures

Quality Improvement

• Meets all standards and requirements as indicated by licensing and accrediting agencies
• Submits verification of current employment related documents per HSCC policies, procedures and licensing agencies

• Completes and submits all documentation in accordance with policies and procedures
• Participates in activities that affirm, enhance and develop the highest quality standards for HSCC
• Participates in developing standards for quality patient care within HSCC
• Participates in Quality Assessment & Improvement activities as requested
• Verbal communication is concise, organized and timely per HSCC guidelines
• Completes and submits all documentation in accordance with policies and procedures
• Submits verification of current RN License, ongoing TB status/tests and passes OIG/GSA/SAM checks per HSCC policies, procedures and licensing agencies

IDG Participation

• Functions as a member of the HSCC IDG maintaining open & organized communication with hospice staff, volunteers and supervisor
• Functions as Nurse Case Manager for hospice pts/families in the coordination/provision of nursing services
• Participates in IDG meeting per protocol to promote problem solving, care planning and learning
• Maintains open, organized and timely communication with hospice staff / volunteers
• Works collaboratively with IDG to develop common goals to meet the needs of the patient and family

Special Projects

• Participates in special projects as requested
• Performs other related job duties as assigned by Supervisor

Compliance

• Ensures all HIPAA Privacy and Security Regulations, Medicare Conditions of Participation, and all other regulatory/compliance requirements are understood and followed
• Submits verification of current RN license
• Ensures TB/FIT checks are completed in a timely manner; at least annually

Requirements

Certifications, Licenses, Registrations

• Require current California RN license
• Valid state driver's license and liability auto insurance
• Pass OIG/GSA/SAM review and all required background checks

Education/Experience

• Degree in Nursing from an accredited college
• 2-5 years RN experience in hospice, oncology, medsurg, ICU, ER, skilled nursing facilities or homecare
• 1 year minimum of Acute care experience preferred
• Previous experience working with electronic medical record charting is desirable
• Hospice and/or home health experience preferred
• End-of-life and pain management experience preferred
• Prefer technical experience with ports, IV's, TPN, Oncology, Medsurg, ICU or Homecare and Electronic Medical Record keeping
• Requires ability to effectively manage self and stress related to end-of-life/death and dying experiences. Experience in handling emotionally charged situations in calm, respectful manner. And has strong coping skills

Skills Desired

• Previous experience working with end of life is desirable
• Bilingual in English/Spanish encouraged but not required

Physical Demands

• Sufficient dexterity to utilize electronic record keeping systems, computers/keyboards and or laptops and other related equipment
• Ability to travel to patient locations; includes ability to drive, negotiate stairs and walkways including uneven surfaces at private homes or facilities
• Vision ability to read manual and electronic documentation, medications, charts, office related equipment, and instructions
• Hearing ability within normal range to elicit and detect pertinent information while communicating with patients and health team
• Speech to verbally communicate to assess and impart information concerning patient status; to complete patient/family teaching and to interact with health care team

Work Environment/Environmental Condition

• Performs services in private homes and care facilities and will experience a variety of settings and situations
• Office work is performed in typical office setting