Registered Nurse, Case Manager - Care at Home

Home Health Nurse Case Manager Job Description

Job Summary

The Home Health Nurse Case Manager is a professional nurse who coordinates and directs the home care patients care based on individual patient needs. The Nurse Case Manager is responsible for independent management of the Home Health patient population requiring the use of advanced assessment, teaching, and decision-making skills.

Responsibilities

• Assessment: • Assesses physical, functional, psychosocial, and cognitive status of the home care patient utilizing interview, observations, and physical exam techniques. • Assesses the home environment for safety, infection control, and community resource needs. • Collects information for assessment with the patient, family, physician, and other health care team members. • Incorporates multidisciplinary data into the nursing assessment of the home care patient. • Provides ongoing nursing assessment with the patient, family, and home environment to determine physiologic or psychosocial risk. • Applies previous nursing experience and base of knowledge and adapts with the patient and family in a home setting. • Assesses for the presence of advanced directives and facilitates further action in obtaining information about or implementing advanced directives if indicated.

• Planning: • Plans with the patient, family, and physician for care which is feasible within the physical, financial, and emotional resources of the family. • Establishes individualized, measurable goals in consultation with the patient, family, and other health care providers. • Anticipates home care needs and seeks a wide range of community resources to facilitate problem solving. • Develops standards of care for patients in the home setting. • Utilizes home care standards and regulatory guidelines in developing an individualized care plan with each patient and family.

• Implementation: • Provides skilled nursing care, preventative rehabilitative procedures, and prescribed treatments with a variety of patient populations within various potentially complex home situations. • Maintains technical skills according to agency standards, as measured by competency assessments during orientation and annually. • Implements safe, competent care with home care patients and families within Halifax Health policies, procedures, and standards of care. • Accurately follows established infection control and safety policies and procedures. • Directs the use of equipment and supplies in an efficient and cost-effective manner. • Coordinates and directs the care of a caseload of home patients. • Sets priorities of home care caseload adapting to the changing needs of the home care patients and families. • Works collaboratively with multiple community resources to best meet the needs of the home care patient and family. • Documents components of the nursing process to reflect a comprehensive and integrated approach to nursing care.

• Evaluation: • Evaluates patients responses to care based on a continuing assessment and analysis of nursing intervention and alternatives for nursing care. • Initiates change in the care plan based on this evaluation. • Informs the physician, nurse manager, and other appropriate members of the health care team of changes in the patients condition and needs. • Facilitates and coordinates interdisciplinary care conferences with groups of complex patients. • Exhibits sound nursing judgment and decision-making skills in coordinating patient care.

Patient, Family, and Caregiver Education

• Identifies and adapts teaching materials with home care patients and families.
• Involves the home care patient and family in identification of individual requirements/perceptions of learning needs.
• Continually assesses patient/family level of understanding and adjusts teaching and plan of care accordingly.
• Ensures that the home care patient and family demonstrate the knowledge and abilities regarding home care rights and responsibilities, diagnosis, health care status, treatment, skills, medication regime, advance directives, and adaptive behaviors gained as a result of teaching interventions.
• Develops, implements, and evaluates teaching programs with home care patients and families.

Skills, Experience, and Licensure

• Graduate of an accredited school of nursing with an Associate Degree in nursing.
• Two (2) years of recent acute care experience in an institutional setting.
• Bachelors degree with one (1) year of home health care experience preferred.
• Current licensure in state and CPR certification.
• Management experience not required.
• Excellent observation, verbal and written communication skills, problem-solving skills, basic math skills, and nursing skills per competency checklist.

Physical Demands

• Ability to lift up to 50 pounds with frequent lifting and/or carrying objects weighing up to 25 pounds.
• Prolonged or considerable walking or standing.
• Able to lift, position, or transfer patients.
• Able to lift supplies and equipment.
• Considerable reaching, stooping, bending, kneeling, or crouching.
• Visual acuity and hearing to perform required nursing skills.
• Must be able to travel in a vehicle daily, visiting between 1-7 homes a day, to deliver personal care to patients.
• Must be able to climb stairs and gain access to a variety of different dwellings to deliver care, in various inclement weather conditions, including snow and ice.
• Must be able to type on a laptop computer keyboard for medical record data entry associated with each patient visit.

Work Environment

• The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.
• Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
• While performing the duties of this job, the employee is frequently exposed to fumes or airborne particles.
• The employee is occasionally exposed to toxic or caustic chemicals and outside weather conditions.
• The noise level in the work environment is usually quiet.

Special Equipment/Work Aids

• Department-appropriate scrubs, bag, and PPE equipment.
• Home Health issued IPAD for documentation in EMR system.
• Individual should have the knowledge of database software, Internet, word processing, and Excel.