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Responsible for identifying and coordinating patient/family care to support terminally ill patients and families in all hospice settings. The Case Manager utilizes teaching, assessment, and intervention skills to provide comfort care at end of life and maximize the quality of life for the patients and families.
Job Responsibility:
Responsible for identifying and coordinating patient/family care to support terminally ill patients and families in all hospice settings
Frequency of patient / family contacts will be at the discretion of the Case Manager and his/her assessment of need, but will be a minimum of every 15 days
The Case Manager utilizes teaching, assessment, and intervention skills to provide comfort care at end of life and maximize the quality of life for the patients and families
Educates patients and families regarding disease processes and trajectory, disease management, hospice philosophies, signs and symptoms of decline and end of life
Updates the primary physician as indicated and according to agency, accreditation, state and federal requirements
Responsible for continuous review of all aspects of every patient of her/his caseload to include appropriate utilization of services and the appropriate hospice level of care criteria are met
Makes referrals to other team members as appropriate
Administers medication and treatments as prescribed by the physician
Leads the interdisciplinary care group (IDG) specific to each patient and family on their caseload
Working within the IDG to develop, revise, and implement the patient’s Plan of Care
Coordinates all services and collaborates with members of the interdisciplinary team to provide consistent patient care
Arranges for and/or recommends equipment, medical supplies and other necessary items and services as indicated
Enters, completes and updates documentation in the electronic health record as required according to agency/department standards and policies, accreditation, state and federal guidelines
Documentation accurately records the patient’s experience with a combination of assessments and narrative
Provides on-going assessment of patient response to treatments, medications and teaching while making appropriate changes in interventions and follow-up to meet patient needs
Updates and revises POC as indicated with supportive documentation to changes
Communicates problems and changes in condition to physicians, supervisor and other members of the IDG
Enters verbal orders from the physician or APN into the Electronic Health Record
Supervises and performs Home Health Aide and licensed practical nurse supervisory visits according to agency standards
Instructs paraprofessional staff on a timely basis and in accordance with agency, state and federal regulations
Facilitates the discharge planning process according to agency standards and utilizes interagency/system and community resources to assure continuity of care after discharge
WI ONLY: May conduct OASIS assessments for Palliative Care patient and establish and update the plan of care
May conduct hospice initial and comprehensive assessments and establish and update the plan of care
Ensures continued skilled nursing/home bound criteria are met
Initiates appropriate preventive and rehabilitative nursing procedures
Utilizes proper body mechanics, assistive devices and safety techniques when performing various patient positioning/repositioning and transporting duties, which require lifting, and pushing/pulling
Orients and mentors new staff as requested
Must be able to demonstrate knowledge and skills necessary to provide care appropriate to the age of the patients served
Must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify each patient's requirements relative to his/her age-specific needs, and to provide the care needed as described in the department's policies and procedures
Requirements:
Registered Nurse license issued by the state in which the team member practices
Basic Life Support (BLS) for Healthcare Providers certification issued by the American Heart Association (AHA) needs to be obtained upon hire unless department leader has determined it is not required
A valid driver’s license issued by the Division of Motor Vehicles
Completion of an accredited or approved program in Nursing
Typically requires 1-2 years of experience in nursing that includes experiences in home health, hospice, medical/surgical, long term care, emergency care/ICU or oncology or similar related experience
Competent in the principles of deformity prevention, normal range of motion, body mechanics and body alignment
and fundamental principles of human behavior and an understanding of the effects of stress upon individuals and groups
Excellent awareness and perception skills, for the purpose of assessing a patient's needs, concerns and to recognize changes in their health condition
Excellent communication and interpersonal skills
Excellent decision making and critical thinking skills, with the ability to work independently and make sound judgments
Excellent prioritization and organizational skills
Must be able to: Lift up to 50 lbs. from floor to waist
Lift up to 20 lbs. over the head
Carry up to 40 lbs. a reasonable distance
Must be able to: Push/pull with 30 lbs. of force
Perform a sliding transfer of 150 lbs. with a second person present
Must be able to work safely with people of various sizes and weight, with diverse and complex medical conditions and physical limitations
Must have the physical agility and stamina to move about in confined spaces, including bending, kneeling, squatting and occasionally reaching one or both arms over the head for long periods of time
Will be exposed to the following hazards on a frequent basis: mechanical, electrical, chemical, blood and body fluids
Will be required to wear protective clothing and equipment as needed
Must have functional speech, vision, hearing, and touch with ability to use fine-hand manipulation skills
Operates all equipment necessary to perform the job
What we offer:
Paid Time Off programs
Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
Flexible Spending Accounts for eligible health care and dependent care expenses
Family benefits such as adoption assistance and paid parental leave
Defined contribution retirement plans with employer match and other financial wellness programs