Signature Coast Home Health and Hospice Case Manager RN | Full Time | Lincoln City, OR

Signature Healthcare at Home•Lincoln City, OR

22d

About The Position

JOB SUMMARY The registered nurse plans, organizes and directs hospice care and is experienced in nursing, with emphasis on community health education/experience. The professional nurse builds from the resources of the community to plan and direct services to meet the needs of individual and families within their homes and communities. DUTIES & RESPONSIBILITIES Hospice Patient Care for Hospice Completes an initial, comprehensive and ongoing assessments of patient and family to determine hospice needs. Provides a complete physical assessment and history of current and previous illness(es). Provides professional nursing care by utilizing all elements of nursing process. Assesses and evaluates patient’s status by: Writing and initiating plan of care. Regularly re-evaluating patient and family/caregiver needs while participating in revising the plan of care as necessary. Uses health assessment data to determine nursing diagnosis. Develops a care plan that establishes goals, based on nursing diagnosis and incorporates palliative nursing actions. Includes the patient and the family in the planning process. Initiates appropriate preventive and rehabilitative nursing procedures. Administers medications and treatments as prescribed by the physician in the physician’s plan of care. Counsels the patient and family in meeting nursing and related needs. Provides health care instructions to the patient as appropriate per assessment and plan. DUTIES & RESPONSIBILITIES Home Health Patient Care for Home Health Develops and initiates the plan of care and assumes responsibility for the ongoing interdisciplinary assessment and development of the individualized plan of care in partnership with the patient, representative (if any), and caregiver(s); Initiates proper preventative and rehabilitative nursing procedures and provides services that are ordered by the physician as indicated in the plan of care; Provides patient, caregiver, and family counseling; Provides patient and caregiver education; Prepares clinical notes; Communicates with the physician who is responsible for the home health plan of care and other health care practitioners (as appropriate) related to the current home health plan of care. Identifies discharge planning needs as part of the care plan development and implements prior to discharge of the patient. Prepares clinical notes and updates the primary physician when necessary and at least every sixty days. Communicates with the physician regarding the patient’s needs and reports any changes in the patient’s condition; obtains/receives physician’s orders as required. Communicates with community health related persons to coordinate the care plan. Additional Duties Participating in the HHA's quality assessment and performance improvement program and HHA-sponsored in-service training. Participates in on-call duties as defined by the on-call policy. Ensures that arrangements for equipment and other necessary items and services are available. Instructs, supervises and evaluates home health aide care provided every two (2) weeks. Supervises Licensed Practical Nurses (LPNs)/ Licensed Vocational Nurses (LVNs) and/or Home Health Aids (HHAs)/Certified Nursing Assistants (CNAs), as directed. Additional Duties for Hospice Participates in on-call duties as defined by the on-call policy. Ensures that arrangements for equipment and other necessary items and services are available. Supervises ancillary personnel and delegates responsibilities when required. Assumes responsibility for personal growth and development and maintains and upgrades professional knowledge and practice skills through attendance and participation in continuing education and in-service classes. Fulfills the obligation of requested and/or accepted case assignments. Actively participates in quality assessment performance improvement teams and activities. The above statements are only meant to be a representative summary of the major duties and responsibilities performed by the employee of this job. The employee may be requested to perform job-related tasks other than those stated in this description.

Requirements

Graduate of National League for Nursing accredited school of nursing.
Minimum of two years of experience, at least one of which is in the area of public health, home care, or hospice nursing is preferred.
Management experience not required.
Responsible for supervising hospice aides.
Registered nurse with current licensure to practice professional nursing in the state.
Demonstrates excellent observation, problem solving, verbal and written communications, nursing skills per competency checklist.
Shows ability to organize and prioritize workload independently.
Prolonged or considerable walking or standing.
Able to lift, position, and/or transfer patients.
Able to lift supplies and equipment.
Considerable reaching, stooping, bending, kneeling, and/or crouching.
Visual acuity and hearing to perform required nursing skills.
Maintains a current CPR certification.
The ability to drive and/or have access to transportation for agency related travel (e.g. community partners, patients, etc.) is an essential function of the job.
Must have and maintain a valid driver’s license, maintain automobile insurance coverage and have access to an automobile.
Self-directed and able to work with minimal supervision.

Responsibilities

Completes an initial, comprehensive and ongoing assessments of patient and family to determine hospice needs.
Provides a complete physical assessment and history of current and previous illness(es).
Provides professional nursing care by utilizing all elements of nursing process.
Assesses and evaluates patient’s status by: Writing and initiating plan of care.
Regularly re-evaluating patient and family/caregiver needs while participating in revising the plan of care as necessary.
Uses health assessment data to determine nursing diagnosis.
Develops a care plan that establishes goals, based on nursing diagnosis and incorporates palliative nursing actions.
Includes the patient and the family in the planning process.
Initiates appropriate preventive and rehabilitative nursing procedures.
Administers medications and treatments as prescribed by the physician in the physician’s plan of care.
Counsels the patient and family in meeting nursing and related needs.
Provides health care instructions to the patient as appropriate per assessment and plan.
Develops and initiates the plan of care and assumes responsibility for the ongoing interdisciplinary assessment and development of the individualized plan of care in partnership with the patient, representative (if any), and caregiver(s)
Initiates proper preventative and rehabilitative nursing procedures and provides services that are ordered by the physician as indicated in the plan of care
Provides patient, caregiver, and family counseling
Provides patient and caregiver education
Prepares clinical notes
Communicates with the physician who is responsible for the home health plan of care and other health care practitioners (as appropriate) related to the current home health plan of care.
Identifies discharge planning needs as part of the care plan development and implements prior to discharge of the patient.
Prepares clinical notes and updates the primary physician when necessary and at least every sixty days.
Communicates with the physician regarding the patient’s needs and reports any changes in the patient’s condition; obtains/receives physician’s orders as required.
Communicates with community health related persons to coordinate the care plan.
Participating in the HHA's quality assessment and performance improvement program and HHA-sponsored in-service training.
Participates in on-call duties as defined by the on-call policy.
Ensures that arrangements for equipment and other necessary items and services are available.
Instructs, supervises and evaluates home health aide care provided every two (2) weeks.
Supervises Licensed Practical Nurses (LPNs)/ Licensed Vocational Nurses (LVNs) and/or Home Health Aids (HHAs)/Certified Nursing Assistants (CNAs), as directed.
Supervises ancillary personnel and delegates responsibilities when required.
Assumes responsibility for personal growth and development and maintains and upgrades professional knowledge and practice skills through attendance and participation in continuing education and in-service classes.
Fulfills the obligation of requested and/or accepted case assignments.
Actively participates in quality assessment performance improvement teams and activities.