Hospice RN Case Manager for Burlington and Walworth Hospice Team

Responsibilities

• Responsible for identifying and coordinating patient/family care to support terminally ill patients and families in all hospice settings. Frequency of patient/family contacts is at the discretion of the Case Manager and assessment of need, with a minimum of every 15 days. The Case Manager utilizes teaching, assessment, and intervention skills to provide comfort care at end of life and maximize the quality of life for patients and families.
• Educates patients and families regarding disease processes and trajectory, disease management, hospice philosophies, signs and symptoms of decline and end of life. Updates the primary physician as indicated and according to agency, accreditation, state and federal requirements.
• Responsible for continuous review of all aspects of every patient in the caseload to ensure appropriate utilization of services and that the appropriate hospice level of care criteria are met. Makes referrals to other team members as appropriate.
• Administers medications and treatments as prescribed by the physician.
• Leads the interdisciplinary care group (IDG) specific to each patient and family on their caseload. Works within the IDG to develop, revise, and implement the patient’s Plan of Care. Coordinates all services and collaborates with IDG members to provide consistent patient care. Arranges for and/or recommends equipment, medical supplies, and other necessary items and services as indicated.
• Enters, completes, and updates documentation in the electronic health record as required according to agency/department standards and policies, accreditation, state and federal guidelines.
• Documentation accurately records the patient’s experience with assessments and narrative.
• Provides ongoing assessment of patient response to treatments, medications and teaching; makes appropriate changes in interventions and follow-up to meet patient needs. Updates and revises the Plan of Care as indicated with supportive documentation. Communicates problems and changes in condition to physicians, supervisor and IDG members. Enters verbal orders from the physician or APN into the EHR.
• Supervises Home Health Aide and licensed practical nurse supervisory visits according to agency standards. Instructs paraprofessional staff in a timely manner and in accordance with agency, state and federal regulations.
• Facilitates the discharge planning process according to agency standards and utilizes interagency/system and community resources to assure continuity of care after discharge.
• WI ONLY:
  May conduct OASIS assessments for Palliative Care patients and establish/update the plan of care. May conduct hospice initial and comprehensive assessments and establish/update the plan of care. Ensures continued skilled nursing/home-bound criteria are met. Initiates appropriate preventive and rehabilitative nursing procedures.

• Utilizes proper body mechanics, assistive devices and safety techniques when performing various patient positioning/repositioning and transporting duties, including lifting and pushing/pulling. Orients and mentors new staff as requested.
• Must be able to demonstrate knowledge and skills to provide age-appropriate care and to assess data reflective of the patient’s status and needs, according to department policies and procedures.
• Must have the physical ability to perform tasks described in the job description.

• Registered Nurse license issued by the state in which the team member practices.
• Basic Life Support (BLS) for Healthcare Providers certification issued by the American Heart Association (AHA) to be obtained upon hire unless determined not required by department leadership.
• A valid driver’s license issued by the Division of Motor Vehicles.

• Completion of an accredited or approved program in Nursing.

• Typically requires 1-2 years of nursing experience, including home health, hospice, medical/surgical, long-term care, emergency care/ICU or oncology or related fields.

• Competent in the principles of deformity prevention, normal range of motion, body…