RN CASE MANAGER FOR HOME HEALTH AND HOSPICE CARE Team – Springfield, VT Position Objective: Manages a case load of facility patients. Assesses, plans, implements, coordinates, and evaluates care for each patient, which includes but is not limited to: appropriate treatment intervention, evaluation of outcomes, and utilization of services to ensure that patient care needs are met. Manages care for hospice patients and skilled nursing located in assigned facilities, assist facilities with identifying perspective hospice patients and care coordination. As low facility census dictates, may be required to perform homecare or hospice visits in the community. Conducts case management meetings in the facilities. Develops and delivers (in conjunction with facility staff) in-service trainings for facility and agency employees, patients and families on appropriate and assistive topics. Will participate in on-call and weekend rotation. Performance Expectations: 1. Develop a plan of care under the direction of patient s physician and in collaboration with the patient, their family and/or the primary care givers upon admission. Periodically reviews the patient care plan and recertifies the patient care plan as appropriate. Coordinates the patient s care plan through interdisciplinary communication and case conferences, as appropriate. Advises other disciplines of discharges in a timely basis. Provides ongoing assessment of the patient s clinical, functional, and emotional status to identify problems and/or progress toward desired goals. Initiates and applies interdisciplinary and therapeutic interventions using appropriate technique; obtains appropriate MD approval. Needs time frame immediately, within 24 hours Supervises ancillary personnel (HCA and Licensed Practical Nurses) and delegates responsibilities when required. Establishes a care plan for paraprofessional services and revises as needed according to agency policy. Completes and submits accurate and relevant clinical notes and other required documentation in a timely manner in accordance with expected agency standards, state and federal regulatory compliance i.e., admission papers and OASIS; clinical notes; day sheets; status change; resumption of care; verbal orders/memos; payer source documentation, including management of authorizations; discharge. Completes all clinical documentation on the laptop and in the home when appropriate and in a timely fashion. Transmits all information twice a day.
1) On-Call – HH will be on-call from 4:30 pm 7:30 pm to ensure the late discharges are processed and urgent patient needs are met. We will have 1 RN on call from each colored team on-call. This expectation will be a shared rotation for all HH nurses.
2) Weekends All HH nurses will be on a rotating weekend schedule to ensure we have adequate staffing coverage.
3) Holidays All HH nurses will be on a rotating holiday schedule to ensure we have adequate staffing coverage.