Oversees and coordinates patient and family care in accordance with hospice philosophy and delivery of care. Provides skilled nursing, including intervention, documentation, supportive care and assessments for assigned patients. The RN Case Manager is a member of the Interdisciplinary Team/Group (IDT/IDG).
KEY REPORTING RELATIONSHIPS:
- Reports to the Clinical Manager or Director of Clinical Services
- Develops and oversees the care plan with patient and family/caregiver, primary physician and members of the IDT/IDG. Reviews and evaluates the patient’s Plan of Care (POC) in IDT/IDG meetings on a regularly scheduled basis. Approaches patient and family care in a holistic manner.
- Coordinates patient care with the physician, NP and all members of the Interdisciplinary Team through ongoing communication and appraisal of patient’s changing condition. Refers to appropriate team member for assistance as needed.
- Ensures the educational needs of the patient and family/caregiver are met in order to promote optimal care.
- Provides continuous assessment and monitoring of the physical, emotional and spiritual needs of the patient.
- Performs complex telephone interviews and triages as appropriate.
- Evaluates the appropriate time to coordinate transfer of patient from home hospice to inpatient care.
- Supervises Certified Nurse Aides (CNA); delegates specific tasks per agency policy.
- Participates in related services, such as community education, team training, staff/board committees and orientation of employees.
- Other duties and responsibilities as assigned.
CLINICAL CORE COMPETENCIES:
- Supports the mission and values of hospice and palliative care.
- Provides patient care (neonates to geriatrics) as determined by the Plan of Care (POC) and in accordance with discipline. Utilizes critical thinking skills, education, mentoring, guidance and interventions to achieve goals of care.
- Possesses knowledge of patient rights; ensuring an atmosphere which allows for the privacy, dignity and well-being of all patients in a safe and secure environment.
- Understands the correlation between excellent patient care and the results of Hospice Item Set, CAHPS and other publicly-reported industry and/or accreditation quality benchmark programs.
- Treats patients, family members and other clients with concern and empathy; respects their confidentiality and communicates in a courteous and respectful manner. Maintains and respects professional and personal boundaries. Adheres to HIPAA regulations, and maintains confidentiality of all patients and families.
- Performs job duties within the standards of practice framework.
- Has proficient nursing skills and pain management knowledge, as well as principles of pharmacology including, medication dosages, calculations, interactions and side effects.
- Works independently with minimum direction, anticipates and organizes workflow, prioritizes and follows through on responsibilities.
- Attends team meetings and in-services on a regular basis. Participates in continuing education and professional development courses, to include annual education requirements as assigned to the discipline.
- Works in a high volume environment with rapidly changing priorities.
- Understands the importance of providing accurate and timely point-of-care documentation in Electronic Medical Record (EMR). Uses, clear concise and professional written and verbal communication.
- Responsible for meeting visit frequency, case load and/or visits per shift requirements; takes on-call rotation as needed and/or assigned.
- Possesses knowledge of necessary computer systems including Microsoft Office, Outlook and agency electronic medical records (EMR).
- Promotes a holistic approach to patient care.
- Cooperates with all co-workers; demonstrates flexibility to perform other duties as assigned.
Minimum Education: Graduate of an accredited school of nursing; BSN preferred.
Minimum Experience: 1-2 years of experience in hospice/palliative care, medical surgical, public health, oncology, acute care or home health.
Required License: Current Colorado RN license. Valid Colorado state driver’s license and proof of auto insurance.
CPR certification (Pathways, The Denver Hospice and Pikes Peak affiliates)
- Ability to lift/push/pull minimum of 50 lbs
- Lifts/positions/ and/or transfers patients
- Lifts supplies/equipment
- Prolonged, extensive or considerable standing/walking/sitting
- Considerable reaching/stooping/bending/kneeling/crouching
- Manual dexterity and mobility
- Visual and auditory acuity
- May be exposed to infections and contagious diseases
- Regularly exposed to risk of blood borne diseases
- Occasional exposure to radiation hazards
- Occasional exposure to unpleasant patient or unit elements (sound, odor, sight, behavior)
- May perform emergency care
- Exposure to variety of electro-mechanical hazards
- Subject to varying and unpredictable situations
- Able to maintain job performance in emergency or crisis situation