RN Case Manager

The Visit Nurse works in conjunction with the Nurse Case Manager, Director of Nursing (DON) and the Interdisciplinary Team to:

• provide hands-on clinical nursing, interacting with patients, family, physicians, Interdisciplinary Team members, and other health care professionals involved in the patient’s care.

• assess and coordinate a pain/symptom management program formulated with the participation of family and patient, attending physician and the Interdisciplinary Team, utilizing pharmacological and non-pharmacological methods of pain/symptom control to enhance quality of life.

• assist in facilitating freedom of choice, relief of suffering and death with dignity for patients facing end of life issues.

• provide support and education for families based on the hospice philosophy of care. Care includes physical, psychological, spiritual, and financial comfort.

• participate in Interdisciplinary Team meetings and up-dates the Plan of Care (POC) for assigned patients based on identified problems and needs.

• ensure all services provided are in accordance with the patient’s POC.

• ensure the POC involves the active participation of the patient, family, PCP, and the Interdisciplinary Team

• provide Nurse Case Manager with appropriate information to coordinate all services related to hospice care for assigned patients. Coordination of services include communicating and making referrals for home health aide/homemaker, chaplain, social worker, volunteer, and ancillary services, as well as ordering medications and Durable Medical Equipment

• educate patient and family on the disease process and expectation related to the disease progression.

• assist with CQI activities.

• work as a team member at all times and uphold the Hospice Code of Ethics

• provide care to manage patient symptoms.

• utilize the medication formulary whenever possible for the management of patient symptoms.

• reports to DON as patient condition changes, changes in the patient condition that require change in level of care.

III. Orientation and TRAINING

Hospice will provide orientation and training, as necessary, to assist the Case Manager Nurse in performing the responsibilities listed above. Training may be in-house or outside seminars. Evidence of orientation and training will become part of the personnel file.

IV. On Call

The Case Manager Nurse will be on call according to scheduling. During the hours when on call, the Visit Nurse is expected to follow On Call Protocol and to respond to all pages within 20 minutes.

V. Accountability

Reports directly to the Nurse Case Manager and Director of Nursing. The Nurse Case Manager will work under the direction of the Director of Nursing.