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RN Case Manager - Home Hospice

Company: Unity Point Health
Location: Waterloo
Posted on: November 13, 2020

Job Description:

Job Description:

The RN Case Manager uses clinical nursing knowledge, physical assessment, teaching and procedural skills to deliver high quality patient care in the patient's place of residence. The RN Case Manager develops and oversees the hospice plan of care under the direction of the physician and ensure appropriate interdisciplinary involvement to ensure the best outcome for each patient. The RN Case Manager delivers patient care directed by the physician as established in the hospice plan of care that is consistent with clinical best practices and results in high quality, improved outcomes and exceptional patient experience. Responsibilities Patient Care/Care Coordination Ensures compassionate, empathetic quality and safe delivery of services to patients according to care plan. Consistently utilizes a patient-centered approach considering physical, psych/social, spiritual, educational, safety and related criteria appropriate to the age of the patients served in hospice. Integrates and coordinates the care of the at-risk population across the healthcare continuum making assessments, planning interventions working closely with providers and overall patient care team. Facilitates the interdisciplinary plan of care to meet multiple service needs as well as promote continuity through elimination of fragmentation of care/service. Delivers quality care consistent with Hospice Conditions of Participation, qualifying hospice criteria, payer coverage criteria, and providing visits/treatments consistent with the plan of care to honor patient/ family values/ wishes Makes visits to the homes of patients and assumes responsibility for an ongoing interdisciplinary assessment of the patient. Performs initial, comprehensive, and recertification assessments on all patients in accordance with agency policies and procedures. Performs nursing assessment at each visit in accordance with agency policies and procedures. Ensures quality and safe delivery of services to patients according to the care plan. Uses equipment and supplies safely, effectively, and efficiently. Provides education to patients and family members to understand the following as well as any additional education needs identified by the assessing clinician and/or physician: o Medications purpose, use, side effects, potential adverse effects o Proper use, safety hazards, and infection control issues related to the use and maintenance of any equipment provided o Patient plan of care o Emergency preparedness o Disease progression and management of symptoms Provides the services that are ordered by the physician as indicated in the plan of care. Provides patient, caregiver and family counseling and education as indicated in the plan of care. Includes the patient, representative and caregiver in all plan of care decisions. Assesses the need for plan of care updates and every visit and includes the patient and family in care planning decisions and communicates care plan revisions to the patient, representative, caregiver and all physicians issuing orders for the home health plan of care. Maintains accurate and timely documentation of clinical records and time/travel entries. Receives, relays and documents verbal orders in accordance with state and federal regulations and in a timely manner to prevent adverse patient outcomes. Is responsible for obtaining physician orders prior to initiation of care and notifying the physician of any changes in the patient's condition. Communicates with all physicians involved in the plan of care and other health care practitioners related to the current plan of care. Identifies patient's risks for hospitalization and/or emergency department use and proactively intervenes to prevent adverse events. Supervises home health aide and licensed practical nurse staff and documents supervision in the patient medical record. 70% Hospice Performance Criteria Delivers quality care and completes clear, concise and accurate clinical documentation of care provision in accordance with home health conditions of participation (CoPs), various payer home health coverage criteria, accreditation standards, professional standards for discipline/credential and the home health plan of care. Maintains competence in HIS data collection and documentation and submits all initial and corrected assessments according to CMS guidance and agency policies and procedures. Participates in clinical review of records to monitor quality and accuracy, appropriate utilization, appropriate involvement of interdisciplinary team members, appropriate referrals and coordination of care. Participates in peer review and other quality assurance activities, as assigned. Uses appropriate infection control procedures and safety measure to protect employees and patients. Provides patient and family education using UPaH approved patient teaching materials only. Participates in IDT, in-service programs and other meetings required to ensure coordin

Keywords: Unity Point Health, Waterloo , RN Case Manager - Home Hospice, Healthcare , Waterloo, Iowa

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