Summary:

The Hospice Registered Nurse (RN) Case Manager provides nursing care and case management to patients and families within and outside of The Highlands at Wyomissing campus. Implements nursing interventions and coordinates the Patient/family interdisciplinary plan of care. Supervises personnel to deliver care and coordinate care delivery.

Essential Functions:

Patient Care

• Completes initial, comprehensive, and ongoing assessments 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
• Uses health assessment data to determine nursing diagnosis.
• In conjunction with the Interdisciplinary Group (IDG) 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.
• In conjunction with the Physician, adds medications and treatments as prescribed by the physician in the Patient’s plan of care.
• Counsels the patient and family in meeting nursing and related needs.
• Provides health care instructions to the patient/family as appropriate per assessment and plan.
• Assists the patient, as needed with the activities of daily living and facilitates the patient’s efforts toward self-sufficiency and optional comfort care.
• Assumes responsibility to coordinate patient care for assigned caseload.

Communication

• 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/IDG regarding the patient’s needs and reports changes in the patient’s condition; obtains/receives physicians’ orders as required.
• Communicates with IDG and 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 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 Members to meet the emotional needs of the patient and family/caregiver.
• Attends interdisciplinary group meetings.

Additional Duties

• 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 when 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.
• Care will be provided to residents on The Highlands at Wyomissing campus and surrounding communities.

Education and Experience Requirements:

• Registered nurse with current licensure to practice professional nursing in the state of Pennsylvania and in good standing with the State Board of Nurses.
• Maintains a current CPR certification.
• Must be a licensed driver with an automobile that is insured in accordance with state or organization requirements and is in good working order.
• A minimum of two years experience, at least one of which is in public health, home care, or hospice nursing is preferred.