Hospice Nurse Case Manager

Mozaic Senior Life•Bridgeport, CT

About The Position

The Hospice Nurse Case Manager coordinates and manages individualized hospice care for an assigned caseload of patients and families. The position provides skilled nursing assessment and intervention, manages pain and other symptoms, coordinates the interdisciplinary plan of care, and promotes comfort, dignity, quality of life, and patient and family goals throughout the end-of-life experience. The Nurse Case Manager is a primary clinical point of contact for patients, families, caregivers, physicians, and interdisciplinary team members. The role identifies, communicates, and addresses changes in patient condition and care needs promptly, and ensures the nursing component of each individualized plan of care reflects changing needs and goals.

Requirements

Graduate of an accredited school of nursing.
Current Registered Nurse license in the State of Connecticut.
Current driver's license and ability to travel throughout the service area as required.
Ability to perform physical functions necessary for nursing care in home and community settings, including standing, walking, bending, reaching, and assisting with patient-care activities as appropriate.
Ability to travel between patient locations and function safely in varied home and facility environments.
Ability to manage multiple priorities, respond appropriately to changes in patient condition and urgent situations, communicate effectively during emotionally difficult circumstances, and maintain professional judgment and composure when supporting people experiencing serious illness, dying, death, and grief.

Nice To Haves

Hospice, palliative care, home care, or related clinical experience.
Experience caring for patients with serious or life-limiting illness.

Responsibilities

Manage an assigned caseload of hospice patients and coordinate care across the hospice interdisciplinary team.
Complete comprehensive and ongoing nursing assessments, identifying changes in physical, functional, psychosocial, emotional, spiritual, and safety needs within the RN scope of practice.
Develop, implement, evaluate, and update the nursing component of individualized hospice plans of care in collaboration with patients, families or caregivers, physicians, and the interdisciplinary team.
Provide skilled nursing interventions focused on comfort, pain and symptom management, and quality of life.
Monitor responses to medications, treatments, and interventions; promptly communicate significant changes in condition to appropriate providers and team members.
Anticipate changing patient needs and facilitate timely interventions to help prevent avoidable crises and support patient goals and preferred care settings.
Educate patients and families or caregivers about disease progression, medications, symptom management, comfort measures, equipment, safety, and expected changes in condition.
Provide emotional support and guidance while maintaining appropriate professional boundaries.
Coordinate hospice aide and other discipline services, ensuring care aligns with the individualized plan of care.
Develop and oversee hospice aide plans of care and perform required supervision in accordance with applicable requirements and agency policy.
Participate in interdisciplinary meetings, share current patient information, and collaborate in reviewing and revising care plans.
Maintain timely, accurate, and complete clinical documentation in accordance with requirements, agency policy, and professional nursing standards.
Coordinate care with physicians, facilities, pharmacies, durable medical equipment providers, contracted providers, and other community partners.
Coordinate hospice services for patients in or transitioning between home, assisted living, skilled nursing facilities, hospitals, and other care settings.
Identify changes or concerns that may affect hospice eligibility or the plan of care and communicate them to appropriate program leaders and team members.
Participate in patient admissions, intake and triage activities, information calls, and other clinical coverage as program needs require.
Participate in the hospice on-call rotation as assigned and respond appropriately to urgent patient and family needs.
Identify needs for social work, spiritual care, bereavement, volunteer, complementary therapy, and other hospice services, and facilitate appropriate referrals.
Support patient and family understanding of hospice philosophy and participate in goals-of-care discussions within the nurse's role and scope of practice.
Adjust patient visit frequency and other contacts according to assessed needs, condition, goals of care, and the individualized plan of care.
Participate in quality improvement, clinical education, competency activities, case review, and other initiatives to improve care and hospice outcomes.
Maintain confidentiality and protect patient rights in accordance with HIPAA, applicable laws and requirements, and agency policies.
Provide compassionate, culturally responsive, patient- and family-centered care that respects individual values, beliefs, preferences, and goals.
Perform other duties consistent with the position, professional scope of practice, skills and training, and Mozaic's mission and goals.