Job Summary

The Nurse Case Manager (NCM) is a member of the core interdisciplinary team responsible for the care and case management of patient/families admitted to hospice service. The NCM in collaboration with pt/family, physician and interdisciplinary team, develops and coordinates an individualized Plan of Care (POC) that reflects pt/family goals related to Safe & Comfortable Dying, Self-Determined Life Closure and Effective Bereavement. The NCM demonstrates: sensitivity and compassion for the issues involved with serving patients and families facing a terminal illness, death and bereavement; clinical competence in pain and symptom management; and fiscal responsibility in the planning and delivery of services. The Nurse Case Manager provides direct supervision for Hospice Aides and LVNs, when utilized. Occasional weekend availability required.

Essential Responsibilities

Patient/family care

• Recognizes the patient and family as the "unit of care" and active members in the development of the POC
• Respects patient right to self-determination and acts as advocate within the context of the values and ethical standards of HSCC. Meets pt/family where they are
• Utilizes nursing process in providing primary care to pt/families
• Documents all care and care planning per agency policy
• Provides nursing interventions for pt/family as ordered by the physician and in accordance with the POC, safe nursing practice and the policies and procedures of HSCC
• Assesses and monitors management of pain and symptoms in collaboration with patient/family, IDG and physician to achieve maximum comfort
• Exercises good clinical judgment
• Administers medications and treatments as ordered prn
• Demonstrates the ability to articulate the parameters of hospice care and services
• Demonstrates the ability to work with pt/families under stress & in crisis
• Develops, manages, reviews & revises HA POC & supervises HA performance per HSCC policies & procedures
• Reviews and considers patient data gathered by LVN when developing and revising the plan of care.
• Instructs and supports pt/family unit re: symptom mgmt, patient care, disease process & death/dying
• Participates in providing after-hours coverage to pt/family as needed

Case Management

• Visit frequencies are appropriate to patient status
• Plans & provides care within the structure of the Conditions of Participation & the Hospice Medicare/Medi-Cal Benefit
• Collaborates with IDG & Attending Physician to develop, manage, review and revise a written POC that includes identified goals, interventions and outcomes that address pt/family physical, psychosocial and spiritual goals related to Safe & Comfortable Dying, Self-Determined Life Closure and Effective Grieving
• Opens, closes & revises POC per HSCC guidelines
• Documents all contacts/instructions/ interventions per HSCC policies & procedures
• Obtains medications, medical supplies and equipment per pt need/physician order
• Demonstrates understanding of pharmacy-related policies & procedures
• Assess patient's continued appropriateness for hospice care per HSCC Recertification protocols
• Completes Recertification documentation in a timely and accurate manner
• Exercises professional management and coordinates care between and among involved parties in home, SNF and RCFE setting
• Provides concise and timely on call reports
• Submits completed paperwork & time sheets within the timeframes per HSCC policies & procedures

Quality Improvement

• Meets all standards and requirements as indicated by licensing and accrediting agencies
• Submits verification of current employment related documents per HSCC policies, procedures and licensing agencies
• Completes and submits all documentation in accordance with policies and procedures
• Participates in activities that affirm, enhance and develop the highest quality standards for HSCC
• Participates in developing standards for quality patient care within HSCC
• Participates in Quality Assessment & Improvement activities as requested
• Verbal communication is concise, organized and timely per HSCC guidelines
• Completes and submits all documentation in accordance with policies and procedures
• Submits verification of current RN License, TB status, passes OIG/GSA checks, proof of auto insurance/good driving record in a timely manner per HSCC policies, procedures and licensing agencies

IDG Participation

• Functions as a member of the HSCC IDG maintaining open & organized communication with hospice staff, volunteers and supervisor
• Functions as Nurse Case Manager for hospice pts/families in the coordination/provision of nursing services
• Participates in IDG meeting per protocol to promote problem solving, care planning and learning
• Maintains open, organized and timely communication with hospice staff / volunteers
• Works collaboratively with IDG to develop common goals to meet the needs of the patient and family

Special Projects

• Participates in special projects as requested
• Performs other related job duties as assigned by Supervisor

Compliance

• Ensures all HIPAA Privacy and Security Regulations, Medicare Conditions of Participation, and all other regulatory/compliance requirements are understood and followed
• Submits verification of current RN license
• Submits proof of auto insurance annually; keeps drivers license current and maintains a good driving record
• Ensures TB checks are completed in a timely manner; at least annually

Requirements

Certifications, Licenses, Registrations

• Require current California RN license
• Valid state driver's license and liability auto insurance
• Pass OIG/GSA review and all required background checks

Education/Experience

• • Degree in Nursing from an accredited college
  • 2-5 years RN experience in hospice, oncology, medsurg, ICU, ER, skilled nursing facilities or homecare
  • 1 year minimum of Acute care experience preferred
  • Previous experience working with electronic medical record charting is desirable
  • Hospice and/or home health experience preferred
  • End-of-life and pain management experience preferred
  • Prefer technical experience with ports, IV's, TPN, Oncology, Medsurg, ICU or Homecare and Electronic Medical Record keeping
  • Requires ability to effectively manage self and stress related to end-of-life/death and dying experiences. Experience in handling emotionally charged situations in calm, respectful manner. And has strong coping skills

Skills Desired

• Previous experience working with end of life is desirable
• Bilingual in English/Spanish encouraged but not required