RN Case Manager

see attachment Molly sending over

Performance Standards:
Makes minimum number of visits as per level of care or arranges alternative coverage with Team Manager Provide and document ongoing teaching with patient and caregivers, verbally and in writing to include current list of medications, death and dying process Provide and document ongoing assessment of safety Provide and document ongoing teaching regarding changes in patient's ability to perform ADLs, disease progression Weekly and as needed review of hospice plan of care with caregivers and emphasis on calling hospice main phone number for condition changes, questions Thoroughly documents all medication changes, findings, teaching, and assessments in Net Smart Communicates to Hospice team members any changes made during visit or change in patient's status Documents in the EMR while performing visit Complete a full synchronization twice per day Completes documentation and verifies visit in a timely manner as per MJHS policy Uses Clinical Monitoring scales at each and every visit and performs follow up visit or phone call as indicated Assesses current medications for effectiveness and calls MD for changes or additions for uncontrolled symptoms Conducts medication reconciliation with medication profile and orders any refills needed at each visit Ensures that medications are properly identified as covered/non-covered in Net Smart Assess patient for referrals to supportive services such as but not limited to CAT, PT, Volunteer WOCN Obtains and reviews signed orders from physician for changes in patient plan of care Reviews and updates plan of care using PGIs in Net Smart, with each patient visit, when change in condition occurs and prn Reviews each patient at IDT meeting within one week of admission and then every 2 weeks thereafter Reviews & completes with IDT t