As RN Case Manager Float, the following would be performed, excluded, or modified, as required, based on the nature of the need – e.g., short-term fill in for ETO, or extended due to medical leave:
- Completes nursing assessment and updates plan of care, including the
patient and the family in the planning process.
- Provides direct Hospice nursing care to patients in order to maintain highest level of comfort and quality of life, and regularly assesses for patient nursing care needs.
- Manages the individualized patient/family plan of care and makes necessary revisions as status/needs change.
- Consults with physician for appropriate orders and communicates patient’s condition changes and the needs for medical intervention.
- Initiates appropriate interventions and monitors the outcomes.
- Educates the patient/family as appropriate per assessment and care plan, and encourages their participation.
- Records accurate and timely documentation of patient and family contacts and updates the interdisciplinary team.
- Coordinates Hospice nursing care when outside agency involvement is required.
- Assists in providing 24 hour per day/seven day a week on-call coverage to patients and families.
- Ensures necessary medical equipment, supplies, and services are available.
- When required, completes Home Health Aide assignment as needed and makes supervisory visits every 14 days to instruct, supervise, and evaluate home health aid care provided.
- In the RN case manager role she/he is designated as the IDG coordinator and is responsible for collaborating with other IDG team members to ensure that patient and family needs are met.
- Communicates as needed with appropriate external services providers to insure patient/family needs are effectively being met.
As RN Clinical Liaison, the following would be performed, excluded, or modified, as required, based on the nature of the need – e.g., short-term fill in for ETO, or extended due to medical leave:
- Determines if the patient meets criteria for admission into the hospice program through means of visual contact, interviewing the patient and family, and obtaining a medical history through one-on-one contact with the patient and chart review, if appropriate.
- Completes the initial assessment of the admissions process to address the immediate care needs of the patient/family.
- Completes admission and transfer process with patients and families including the explaining hospice services, insurance benefits, and completing required paperwork and all required consents as appropriate.
- Provides education and support related to symptom management and the physical aspects of End of Life care for the patient/family/caregiver and/or facility team as appropriate.
- Communicates patient/family/caregiver immediate needs and significant IDG Care Plan issues to patient’s assigned RNCM and on call staff as appropriate.
- Consults with the physician for appropriate orders and assists in obtaining needed supplies, equipment, medications and /or other available services.
- Enters clear, concise and timely documentation related to contacts made during the patient’s initial Hospice admission and assessment.
The above statements are intended to be a representative summary of the major duties and responsibilities performed by incumbents of this job. The incumbents may be requested to perform job-related tasks other than those stated in this description.
All employees are required to comply with the policies and procedures of Hospice of Holland, Inc. and with all state, federal, and other regulatory requirements. They will also comply with confidentiality laws as described in the Notice of Privacy Practices as well as accepted professional standards and practice.