Description Job Schedule:
Full Time Standard Hours:
40 Job Shift:
Shift 3 Shift Details:
on call for Mansfield Hospice - work one week on and second week off
Work where every moment matters.
Every day, over 30,000 Hartford HealthCare colleagues come to work with one thing in common: Pride in what we do, knowing every moment matters here. We invite you to become part of Connecticut’s most comprehensive healthcare network as a Visiting Registered Nurse.
Hartford HealthCare at Home, the largest provider of homecare services in Connecticut, has been fulfilling our mission for more than 115 years. Our Person-Centered Care Model allows our employees to learn and grow within our organization, all while providing integrated support to the patient. As part of Hartford HealthCare, we leverage cutting edge technology to provide quality care in our client’s home. Most importantly, our employees are appreciated for the real differences they make in both the lives of their clients and their clients’ families.
The RN Case Manager provides the necessary and appropriate direct service; consultation and coordination to facilitate expected clinical outcomes for home care and hospice patients and their families. The RN coordinates the plan of care in consultation with the Hospice Interdisciplinary Team, and in accordance with the attending physician’s orders and Agency policies, procedures and practices. Delegates appropriate patient care responsibilities to LPN and Home Health Aides, and supervises their performance. Teaches and orients LPN, Home Health Aide, patient and family members in the care of the patient. Responsible for accurate, timely, and proficient clinical and reimbursement documentation. Performs related duties in support of the Nursing and Hospice Departments, and the Agency.
• Exhibits critical care case management skills.
• Recognizes and interprets significant physiological and environmental alternations in patients condition and conferences/reports appropriately.
• Develops an appropriate care plan to meet individual patient needs and appropriate utilization under the direction of the MD, and in collaboration with the patient/caregiver and the Hospice Interdisciplinary Team.
• Visits are consistent with plan of care in frequency and duration to obtain appropriate patient care outcomes.
• Meets Agency productivity standards.
• Implements the nursing care plan to provide safe, efficient quality care to patients.
• Communicates finding/updates and provides appropriate follow up to other Agency personnel.
• Evaluates the plan of care on an on-going basis, revising as necessary in accordance with patients' needs including appropriate referrals to other disciplines and/or specialty including preventative and rehabilitative procedures.
• Assesses and observes ongoing physical, psychosocial and spiritual needs of hospice patients, and refers to the hospice chaplain or social worker as appropriate.
• Coordinates patient care with other Agency personnel and community resources i.e. therapists, social workers, Home Health Aide services, physicians, etc., in an appropriate and timely manner. Initiates and participates in case conferences or Hospice Interdisciplinary Team meetings as appropriate.
• Develops and maintains a respectful relationship with patients, caregivers, and physicians to ensure optimum patient outcomes.
• Develops a working knowledge of community resources and an ability to coordinate services with other agencies.
• Works in conjunction with LPN daily and delegates patient care responsibility as appropriate. Communicates with LPN daily and monitors patient care provided by LPN at least monthly.
• Organizes and prioritizes case load needs on a daily basis to ensure that patient needs are met.
• Keeps Clinical Manager informed in a timely manner regarding weekly caseload and/or patient problems so that patient care and staffing needs are consistently met.
• Responsible for clinical and reimbursement documentation to reflect Agency policy and procedure and the delivery of quality and safe Home Health Care.
• Monitors and assures that all paper work, and all necessary communications and other documentation is completed accurately and timely. Examples include, but not limited to: OASIS, MD Orders, patient discharge, patient authorizations, clinical notes, notification to other departments when primary service is being discharged, communications to MD, mailings, filing, data entry, billing etc.
• Prepares and keeps legible records current, on a daily basis, providing all written information regarding service record, visit and non-visit time, statistical sheets and reports to physicians and other personnel, according to expected time frames.
• Develops written patient care goals and expected outcomes according to individualized patient care plans, accurately reflecting interventions.
• Updates and submits written physician orders accurately, in a timely manner according to established timeframes.
• Collects and documents necessary financial and reimbursement information for each patient and provides verbal and written communication as required, to Agency personnel and other reimbursement sources.
• Obtains prior authorization for services when indicated by calling payors and requesting and/or providing verbal or written confirmation, in a timely manner within respective established time frames.
• Completes and processes discharge record within 24 hours after last patient visit, and communicates promptly with other Agency personnel, in an appropriate fashion.
• Delegates Home Health Aide patient care responsibilities and teaches, demonstrates, orients, and supervises performance of Home Health Aide.
• Assesses and develops Home Health Aide Plan of Care for each patient according to patient needs, updating as needed. Provides written Plan of Care individualized for each patient and orients each Home Health Aide to that plan.
• Teaches and demonstrates for the Home Health Aide with regard to specific patient care responsibilities i.e. diet, transfers, ambulating, personal care, etc.
• Teaches, demonstrates, orients, supervises and evaluates LPN, patient/family members and other appropriate caregivers, in the care of the patient.
• Explains the role and function of each Agency discipline to patients and families and the services, which will be provided, in a clear and concise fashion to ensure proper understanding.
• Recognizes and respects cultural differences in regards to health care choices and end-of-life care, allowing the patient and family to practice within their cultural norms to ensure optimal outcomes.
• Promotes patient and caregiver independence by instructing patient and family in self-care techniques, diet, medications, body mechanics and other aspects of care outlined in physician's orders and/or plan of care.
Education & Training: Graduate of a National League of Nursing accredited program with a diploma or Associate’s Degree in Nursing. Bachelor of Science Degree in Nursing preferred.
License/Certification: Current Connecticut RN license, or eligible for RN licensure in Connecticut, or current temporary RN permit. CHPN preferred for Hospice positions.
Experience: Minimum of two (2) years Medical/Surgical with Oncology/Hospice/Palliative experience preferred. Experience in Home Health Care, or Public Health Nursing, or hospice strongly preferred for Hospice positions.
• Knowledge and endorsement of hospice concepts and philosophy of care required.
• Excellent clinical skills, with advanced knowledge in pain and symptom management, and an ability to identify and plan for resolution of issues/problems related to illness and end of life. Excellent communication skills with the ability to effectively interact with patients, families, physicians, co-workers and staff.
• Strong organizational skills.
• Ability to deal effectively with stress and function in crisis situations, and ability to practice Hospice philosophy.
• Strength in ability to exercise independent and sound judgment.
Other: Valid motor vehicle operators license, reliable personal automobile during business hours, and active automobile insurance coverage in accordance with Agency policy.
We take great care of careers.
With locations around the state, Hartford HealthCare offers exciting opportunities for career development and growth. Here, you are part of an organization on the cutting edge – helping to bring new technologies, breakthrough treatments and community education to countless men, women and children. We know that a thriving organization starts with thriving employees-- we provide a competitive benefits program designed to ensure work/life balance. Every moment matters. And this is your moment.
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