Hospice RN Case Manager

Beth Israel Lahey Health•Plymouth, MN

26d•$37 - $82•Onsite

About The Position

When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives. This role involves providing comprehensive care to hospice patients, functioning as a key member of an interdisciplinary team. The Hospice RN Case Manager acts as the physician's 'eyes and ears' in the home or facility, assessing patient conditions, managing end-of-life pain and symptoms, and ensuring patients meet hospice eligibility criteria. This position requires expert documentation in the EMR, coordination of care plans, and effective communication with physicians, team members, and families. The role also includes educating patients and caregivers, supervising hospice aides, and providing support at the time of death and bereavement. Maintaining competency in end-of-life issues and knowledge of relevant regulations is crucial.

Requirements

Current Massachusetts professional RN license
Baccalaureate degree in nursing from an NLN accredited program preferred
Recent Hospice Case Management or related Home Health Experience required
Expertise in EMR (PTCT) required hospice documentation
Demonstrated ability to manage all aspects of terminal care with expertise in pain and symptom management, IV and SC infusion, knowledge of compounded medications
Demonstrated ability to assess and respond to needs of patients and families in a variety of settings required
Demonstrated customer service is essential
Valid Massachusetts driver’s license and access to reliable transportation
Ability to read, write and speak English
Comprehensive knowledge and skills of current end of life nursing practices
Skilled in interdisciplinary team approach to care and nursing process
Ability to communicate effectively with people from a variety of backgrounds
Ability to present in a self-assured, professional manner while functioning independently in a variety of settings
Ability to sustain positive attitude and personal connections despite exposure to continual personal/professional loss

Nice To Haves

Baccalaureate degree in nursing from an NLN accredited program
Hospice & Palliative Care or Holistic Nursing certification preferred

Responsibilities

Provides care according to and is able to articulate hospice philosophy
Functions as a member of an interdisciplinary team that includes the patient and family in the development of a patient specific plan of care driven by the patient’s goals and preferences.
Functions as the “eyes and ears” of the physician in the home or facility, communicates an accurate assessment of the patient’s condition to the physician and offers expert guidance on treating end-of-life pain and other symptoms when requested by the physician
Performs RN pronouncement in all settings except the acute care hospital
Provides an initial assessment in conjunction with established LCD guidelines to ensure patient meets criteria for admission to hospice.
Provides assessment and clear documentation in the EMR (PTCT) to demonstrate patient continues to meet hospice eligibility utilizing appropriate scales (i.e. FAST, ECOG, etc.)
When services of the hospice chaplain and/or social worker are declined by the patient/family, obtain data on psychological, social and spiritual factors that may influence the patient’s plan of care.
Seeks input from other members of the team to increase knowledge and support.
Provides skilled service that ensures the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment and updated assessments
Prepares and submits updates to patient care plan for review by the Interdisciplinary Group at least every 14 days and prior to each recertification period.
Assumes primary responsibility for the coordination and management of all aspects of the patient’s plan of care.
Initiates and maintains consistent communication with the attending physician, the Hospice Medical Director, the hospice pharmacist(s), other members of the IDG , hospice office staff, clinical supervisors and directors, other agencies and facilities as needed to coordinate optimal care and use of resources for the terminally ill patient and family
Considers factors related to safety, effectiveness and cost in planning and delivering patient and family care
Proactively informs Clinical Supervisor or Clinical Director of unusual or potential problems.
Works with pharmacist and primary care physician to utilize medications that are optimal and yet cost-effective.
Follows process to arrange for the delivery of medications as ordered, understanding the variation in the process for each care location (ALF, SNF, group home or private home)
Educates patient, family and contracted caregivers on medications and other care processes to maximize patient comfort.
Documents patient care issues, goals and plans in the electronic medical record and exports data to be shared with other clinicians in a timely manner.
Documents in the electronic medical record per agency standards to ensure accurate retrieval of quality indicators.
Meets routinely with staff in assisted living, skilled nursing facilities and/or group homes to coordinate the plan of care
Provides excellent Customer Service to patients, families and facilities, by being knowledgeable and respectful of the patient’s “home” environment and regulatory requirements and preferences of each setting.
Supervise the care provided by Hospice Aides at least every two weeks with an annual face to face supervision
Provide appropriate support at time of death and offers bereavement support
Maintains competency in all end-of-life issues, pain and symptom management
Participates in agency programs and community education as required to promote growth and understanding of hospice care
Demonstrate knowledge of agency policies, State Regulations, the Medicare Conditions of Participation, Joint Commission requirements, Long Term Care Facility regulations, and Assisted Living regulations.
Algorithms for end-of-life symptom management.
Participate in in-service training and education with a goal of achieving RN certification in Hospice and Palliative Care
Participate in Quality and Performance Improvement Activities
Other duties as assigned by Clinical Director