The Registered Nurse Case Manger (RNCM) provides end of life care through direct nursing care to Peaceful Hearts Hospice, LLC patients in all settings. The RNCM is responsible for identifying patient/family needs and for providing skilled nursing assessments, for planning and providing supportive care, and for providing appropriate services in accordance with the attending physician's orders and the interdisciplinary team (IDT) plan of care.
Organization Relationship:
The RNCM reports directly to the Director of Patient Care Services (DCPS).
The RNCM will supervise the care provided by the Licensed Practical Nurses and the Hospice Aides.
Qualifications:
Education and Experience:
Must be a currently licensed, in good standing, Registered Nurse in the state of Nebraska.
Graduate from an accredited school of Nursing.
Experience of two (2) years as a Registered Nurse, preferred.
Experience of two (2) years in hospice, home health or oncology, preferred.
Responsibilities and Duties:
Assume primary responsibility for patient/family caseload, which includes assessing, planning, implementing, and evaluating phases of the nursing process.
Initiate communication with attending physicians, other hospice staff members, and other agencies as needed to coordinate optimal care and use of resources for the patient/family.
Maintain regular communication with the DPCS to review caseload.
Assess and re-assess the nursing needs of hospice patients regularly.
Seek input from other group members regarding the patient plan of care in order to obtain additional knowledge and support.
Work closely with all members of interdisciplinary team.
Obtain data on physical, psychological, social and spiritual factors, which may influence patient/family health status, and incorporate that data into the plan of care.
Attend scheduled interdisciplinary team meetings, with gathered information prepared in advance, to communicate patient's needs and changes.
Maintain a professional relationship with Medical Director and/or other primary physicians. Report all patient changes in condition and responses to interventions and/or medication/symptom concerns to attending physician within a timely matter.
Develop and re-evaluate patient's plan of care, keeping all people who are involved with the patient updated.
Provide wound care when appropriate.
Refer to other disciplines involved in patient care for non-nursing needs (social work, dietician, hospice aide, chaplain, volunteers, holistic), to ensure a team approach to patient care.
Provide hospice skilled nursing services, treatments, and preventative procedures.
Provide education and counsel patient and family members about disease processes and supervise end of life personal cares.
Share in on-call rotation, providing 24-hour/7 day-a-week coverage to patients/families as necessary.
Cover on call support when needed, in the event of another staff members absence.
Maintain up-to-date patient records using computerized medical record system so that problems, plans, actions, and goals are accurately and clearly stated, and changes are reflected as they occur.
Complete documentation within established agency guidelines and to meet regulatory requirements.
Communicate to DPCS any situation where staff is unable to meet a patient's needs or perform a procedure.
Independently organize patient schedules using time management and acuity of patient needs.
Assist with training, teaching or orientation as requested.
Initiate nursing procedures appropriate for the patient's hospice care and safety.
Perform specific nursing procedures (treatments, symptom management, wound care, tube feeding/care, bowel regimen, etc.) as ordered by prescribing physician.
Observe signs and symptoms and report to the physician and IDT members any unexpected changes in the patient's physical or emotional condition.
Assist other nurse/case managers, including assuming primary responsibility for patients when necessary.
Act as a liaison between physician, patient/family, hospice team and facilities, as appropriate.
Provide direct patient care, while offering support to the patient, family, and caregivers.
Supervise and document observance of the hospice aide delivery of care every two weeks, or more often if needed. Inform the DPCS of unusual or potentially problematic patient/family issues observed.
Supervise and document observance of the hospice aide competency every year and place in hospice aide's HR file.
Supervise and document observance of the LPN's care every 30 days. Inform the DPCS of unusual or potentially problematic patient/family issues observed.
Provide care in all settings, including but not limited to skilled nursing facility, assisted living, independent living, or any home setting.
Maintain average caseload of patients, assigned based on acuity and location.
Provide emotional support at time of death to family and caregivers.
Pronounce Time of Death in accordance with county and agency policy, complete necessary documentation and notify MD and family.
Facilitate transfers to and from existing agency to another when necessary.
Triage discharges from other agencies through admission to Peaceful Hearts Hospice, LLC., after adequately reviewing patient's History and Physical, medications and other pertinent information.
Ensure patient needs are met with adequate supplies and that medications are available.
Educate patient and families on end-of-life disease processes and symptoms to expect/report.
Perform specific assignments as directed by DPCS and Administrator.
Independently take referrals and order equipment, complete admissions, deaths, discharges, transfers, and revocations when necessary.
Conduct informational meetings with patients and family members.
Complete consents with patient and/or Power or Attorney (POA) when needed.
Working Environment:
The RNCM must be actively involved in all areas of patient care. The RNCM will primarily be in the field; however, will spend time in the office for meetings, charting, phone calls, etc.
The RNCM position requires the ability to utilize a computer, calculator, cell phone, multi-line telephone, and other related office and nursing equipment.
The RNCM has access to all patient medical records.
The RNCM must have good time management skills.
Transportation:
The RNCM must have a valid driver's license, automobile liability insurance and reliable transportation.
Physician/ADA Requirements:
The RNCM will exert physical efforts on most days which may include kneeling, squatting, reaching, twisting, climbing, walking, and exposure to temperature and humidity changes, and may include lifting and/or transferring a patient when providing patient care.
The RNCM must possess sight/hearing or use appropriate adaptive devices.
The RNCM must provide evidence of an annual TB test and other state-required tests and examinations.
Sitting...........................................................................................2-4 hours/day, often more