Registered Nurse Case Manager, Hospice

JOB DESCRIPTION SUMMARY

The Registered Nurse Case Manager (RN CM) plans, organizes and directs hospice services and is experienced in nursing, with emphasis on community health education/experience.  The RN CM 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.  The RN CM respects and promotes the mission, values and vision of VNA Health.

ESSENTIAL JOB DUTIES AND RESPONSIBILITIES

Patient Care

1. Responsible for providing comprehensive case management to hospice patients.
2. Completes an initial assessment of patient and family to determine hospice care needs.   Provides a complete physical assessment and history of current and previous illness(es).  Admits to appropriate level of service/ care.
3. Assesses and evaluates patients status by:
   1. Writing and initiating plan of care.
   2. Regularly re-evaluates patient and family/caregiver needs.
   3. Revising the plan of care as necessary.
4. Initiates the plan of care and makes necessary revisions as patient status and needs change.
5. Uses health assessment data to determine nursing diagnosis.
6. Develops a plan of care pathway that establishes goals, based on nursing diagnosis and incorporates palliative nursing actions.  Includes the patient and family in the planning process.
7. Initiates appropriate preventive and rehabilitative nursing procedures.   Administers medications and treatments as prescribed by the physician in the physician’s plan of care.
8. Counsels the patient and family in meeting nursing and related needs.
9. Provides health care instructions to the patient as appropriate per assessment and plan.
10. Assists the patient with the activities of daily living and facilitates the patient’s efforts towards self-sufficiency and optional comfort care.
11. Knowledge of state, federal, local and accreditation regulations for the delivery of hospice services.
12. Accountable for financial resources and eligibility under various third party payor sources, Medicare and Medi-Cal.

Communication

1. Completes, maintains and submits accurate and relevant clinical notes regarding patient’s condition and are given.  Records pain/ symptom management changes/ outcomes as appropriate.
2. Communicates with the physician regarding the patient’s needs and reports any changes in the patient’s condition; obtains/receives physicians orders as required.
3. Communicates with community health related persons to coordinate the care plan.
4. 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 other hospice Interdisciplinary Team Members.
5. Provides and maintains a safe environment for the patient.
6. Assists the patient and family/ caregiver and other team members in providing continuity of care.
7. Works in cooperation with the family/ caregiver and hospice Interdisciplinary Team Members to meet the emotional needs of the patient and family/ caregiver.
8. Has working knowledge of state, federal, local, and accreditation regulations in order to provide hospice services to community clients.

Additional Duties

1. Meets daily average productivity standards set by the agency.
2. Participates in on-call and weekend duties as defined by the agency policies.
3. Participates in Quality Management activities.
4. Ensures that arrangements for equipment and other necessary items and services are available.
5. Instructs, supervises and evaluates hospice aide care provided every fourteen days.
6. Participates in educational programs to maintain skills and knowledge of current nursing practice.
7. Meets daily average productivity standard set by the organization.

The above statements are only meant to be a representative summary of the major duties and responsibilities performed by incumbents of this job.  The incumbents may be requested to perform job related tasks other than those stated in this description. All clinical staff are expected to participate as needed in variable shifts, including weekend rotation per staffing needs and departmental holiday rotation.

POSITION QUALIFICATIONS

1. Current and active California RN license.
2. Bachelor’s degree, preferred.
3. Minimum one year acute care experience required.
4. One year recent hospice experience preferred. 
5. Current CPR certification.
6. Licensed driver with insured automobile - in accordance with state and/or organization requirements.
7. Management experience not required.  Responsible for supervising hospice home health aides/ LVNs.
8. Excellent observation, verbal and written communication skills, problem solving skills, basic math skills; nursing skills per competency checklist.
9. Ability to respond independently to life threatening situations.
10. Ability to reason, deduce and carry out complex multiple step processes.
11. Bilingual – Spanish preferred, but not necessary. 

PHYSICAL REQUIREMENTS

1. Ability to lift 25 lbs.
2. Ability to push/pull 50 lbs.
3. Ability to stoop, bend, and squat.
4. Ability to walk up one flight of stairs.
5. Ability to walk one mile.
6. Ability to sit for one hour, minimum.
7. Visual and audio acuity.

STANDARD OF PERFORMANCE: 

VNA Health Evaluation tool.