Home Health - Registered Nurse (RN) Case Manager

JOB DESCRIPTION SUMMARY

The registered nurse case manager for Community-Based Palliative Care services plans, organizes and directs home care services and is experienced in nursing, with emphasis on community health education/experience. The professional nurse builds from the resources of the community to plan and direct services to meet the needs of individuals and families within their homes and communities.

ESSENTIAL JOB FUNCTIONS/RESPONSIBILITIES

Clinical Duties

1. Completes an initial assessment of patient and family to determine home care needs. Provides a complete physical assessment and history of current and previous illness(es).
2. Regularly re-evaluates patient nursing needs.
3. Initiates the plan of care and makes necessary revisions as patient status and needs change.
4. Uses health assessment data to determine nursing diagnosis.
5. Develops a care plan, which establishes goals based on nursing diagnosis and incorporates therapeutic, preventive, and rehabilitative nursing actions. Includes the patient and the family in the planning process.
6. Initiates appropriate preventive and rehabilitative nursing procedures. Administers medications and treatments as prescribed by the physician.
7. Counsels the patient and family in meeting nursing and related needs.
8. Provides health care instructions to the patient as appropriate per assessment and plan of care.
9. Identifies discharge planning needs as part of the care plan development and implements prior to discharge of the patient.
10. Acts as Case Manager when assigned by Clinical Supervisor/Nursing Supervisor and assumes responsibility to coordinate patient care for assigned caseload.
11. In addition to the general competency, the RN Case Manager for palliative care services will demonstrate writtenand practical competency in the following practices of palliative care as stated in the National Consensus Project 'Clinical Practice Guidelines for Quality Palliative Care'
12. processes and structure of care
13. physical aspects of care
14. psychological and psychiatric aspects of care
15. social aspects of care
16. spiritual, religious, and existential aspects of care
17. cultural aspects of care
18. care of the imminently dying patient
19. ethical and legal aspects of care

Communication

1. Prepares clinical notes and updates the primary physician when necessary and at least every sixty days.

2. Communicates with the physician regarding the patient's needs and reports any changes in the patient's condition; obtains/receives physician's orders as required.

3. Communicates with community health related persons to coordinate the care plan.

Additional Duties

1. Participates in on-call duties as defined by the on-call policy.

2. Ensures that arrangements for equipment and other necessary items and services are available.

3. Instructs, supervises and evaluates home health aide care provided every two (2) weeks.