Hospice Registered Nurse Case Manager

Oversee primary caseload of hospice patients and provide skilled professional nursing care to them, their families, and caregivers as prescribed by the physician and in compliance with the Hospice Medicare Conditions of Participation, PA hospice licensure laws, and agency policies and procedures. Provide the initial assessment and comprehensive nursing assessment of patient needs, and collaborate to develop the interdisciplinary group plan of care. Implement the plan of care and reevaluate and revise the Plan of Care relative to the patient’s nursing needs to provide appropriate, comprehensive, and responsive goals and interventions. Work closely with other members of the interdisciplinary team to ensure all patient and family care needs are being met.

Nursing Process

As a member of the interdisciplinary team, the Registered Nurse utilizes the nursing process to contribute to each patient’s total plan of care.

1. Assessing and Planning
   1. Seek and obtain sufficient information necessary to function effectively in the Hospice setting where the patient/family/caregiver is receiving care.
   2. Conduct initial assessment, including physical, emotional and psychosocial aspects, of patient/family/caregiver in a thorough, accurate, compassionate and timely fashion.
   3. Utilize the nursing body of knowledge to provide leadership and guidance to the Interdisciplinary Team in formulating and individualizing the interdisciplinary plan of care to include problem identification, interventions and goals to address palliative comfort measures for the terminally ill patient, family and caregiver.
   4. Contribute to identifying both active and potential needs of the patient and his/her family, which may affect the plan of care.
   5. Consistently collaborate with the physician to plan and implement the medical and nursing plan of care.
   6. Review the comprehensive interdisciplinary plan of care with the Interdisciplinary Team (IDT). Communicate in writing in the clinical record and verbally with the IDT to coordinate interventions and ensure continuity of care.
   7. Facilitate and participate in the IDT care conference and contribute to patient care planning.
2. Case Management

   The Registered Nurse is responsible for managing all patients assigned to his/her primary caseload by utilizing the following methods:

   1. Manage daily visits and assignments for maximum efficiency.
   2. Visit frequencies are according to individual patient needs and acuity.
   3. Visit frequencies are reviewed at least weekly and altered to meet patient needs and acuity.
   4. Patient care visits are coordinated with all interdisciplinary team members in order to utilize manpower resources and provide optimal patient care.
   5. Ensure an adequate and appropriate inventory of supplies and equipment for the provision of patient services and promote the efficient use of equipment and supplies.
   6. Maintain confidentiality in patient related matters.
   7. Demonstrate behavior appropriate as a role model and leader, including adhering to the agency code of conduct.
   8. Demonstrate creativity and critical thinking ability when participating in IDT conferences, developing patient care plans or completing assigned projects.
   9. Assume leadership role to facilitate interdisciplinary care coordination and collaboration.
   10. Function without supervision, utilizing time constructively and organizing assignments for maximum productivity.
   11. Recognize and respond appropriately to verbal and non-verbal cues.
   12. Communicate effectively with all members of the Interdisciplinary Team by:
       • Defending and supporting peer/team decisions and actions.
       • Supporting collaboration and team decisions/plans.
       • Maintaining open communication.
       • Offering suggestions and criticisms constructively.
       • Asking questions and sharing information during Interdisciplinary Team conferences and nursing facility care conferences.
   13. Relate complete and pertinent information in verbal and written communication. Maintain clinical records, statistics, and reports as prescribed and in compliance with local, state and federal laws.
   14. Initiate and maintain open and effective communication with the supervisor as well as members of the Interdisciplinary Team as evidenced by improved patient outcomes.

Qualifications:

Education:

• Graduate of an accredited registered nursing program.
• A bachelor’s degree in nursing is preferred.
• C.H.P.N. (Certified Hospice and Palliative Nurse) certification is preferred.

Experience:

• Hospice experience required.
• Experience with pain and symptom management interventions is preferred.
• Ability to work within an interdisciplinary setting.
• Understanding of Hospice philosophy, principles of death/dying.

Licensure, Registration, and/or Certification:

• Registered Nurse licensed.
• CPR certified.
• Valid driver’s license and reliable transportation that is insured in accordance with PA state requirements.
• Satisfactory references from employers and/or professional peers.
• Satisfactory criminal background check.