RN Case Manager | Home Health

MIDLAND CARE CONNECTION INC•Topeka, KS

About The Position

Midland Care Connection is a not-for-profit, community-based organization in Topeka, Kansas, dedicated to helping older adults and seriously ill individuals stay independent and supported in their homes. Established in 1978, it offers a full continuum of care, including hospice, palliative care, home health, grief and loss counseling, and its signature PACE (Program of All-Inclusive Care for the Elderly) program. Their mission centers on "meeting individual needs through innovative care solutions," and they serve people across multiple counties in northeast Kansas. Home Health Program The home health program historically offers skilled nursing, therapy services, home health aides, and supportive non-medical care aimed at helping people remain independent and avoid institutionalization. People Maintains clinical competencies. Provides patient/caregiver education and training specific to identified needs. Collaborates in the provision of care, treatment and services with the interdisciplinary team to meet patients’ needs and maintain continuity of care between disciplines, programs, services and with other organizations as needed. Participates in agency activities to include interdisciplinary team meetings, staff meetings, and other committee meetings as assigned and educational opportunities. Service Provision of skilled nursing care. Collaborates with the physician(s) and acts as liaison for the care coordination of the designated case load. Develop, direct, oversee and update the home health aide plan of care based on the patient’s needs, strengths, limitations and goals. Assesses patient needs and provides services within scope of practice and based on individualized plan of care appropriate to the patient’s needs, strengths, limitations and goals. Communicates/collaborates with contracting providers regarding services provided. Evaluates care, treatment and services to include active participation in interdisciplinary team meetings Assesses for discharge and/or transfer needs and facilitates the process to ensure that continuity of care, treatment and service is maintained. Supervision of home health aide assigned for the implementation of the patient’s plan of care. Quality Follows policies and procedures in the assessment, planning, intervention, evaluation and documentation of patient and family care. Performs clinical duties within the nursing scope of practice. Documents in electronic record within stated standards provides; complete and accurate supporting documentation. Participates in the agency performance improvement program. Participates in the surveillance, prevention and control of infection. Participates in environmental safety and equipment management procedures. Utilizes information management to support decision making to improve patient outcomes, improve health care documentation, assure patient safety and improve performance in patient care, treatment and services. Growth Completes annual mandatory education requirements. Develops partnerships within the community and educates community members and healthcare providers about Midland Care services Provides education related to hospice to staff in alternate care settings (nursing homes, hospitals, assisted-living facilities, etc.)

Requirements

Current unrestricted State of Kansas License to practice as a Registered Nurse.
Availability of reliable transportation is required.
Knowledge of professional nursing theory, standards of nursing practice, scope of practice and relevant statutes and regulations.
Ability to prioritize work, meet deadlines, handle multiple projects, pay strong attention to detail and accuracy and work under pressure in a cooperative work environment.
Must be self-directed, motivated and flexible.
Must possess a valid Kansas Driver’s License, in force automobile liability insurance and maintain a Motor Vehicle Record (MVR) that meets organization’s insurability standard as defined by Midland policy.
Availability of reliable transportation is required for this position.

Nice To Haves

Home Health or Hospice experience preferred. One year professional medical-surgical experience preferred.

Responsibilities

Maintains clinical competencies.
Provides patient/caregiver education and training specific to identified needs.
Collaborates in the provision of care, treatment and services with the interdisciplinary team to meet patients’ needs and maintain continuity of care between disciplines, programs, services and with other organizations as needed.
Participates in agency activities to include interdisciplinary team meetings, staff meetings, and other committee meetings as assigned and educational opportunities.
Provision of skilled nursing care.
Collaborates with the physician(s) and acts as liaison for the care coordination of the designated case load.
Develop, direct, oversee and update the home health aide plan of care based on the patient’s needs, strengths, limitations and goals.
Assesses patient needs and provides services within scope of practice and based on individualized plan of care appropriate to the patient’s needs, strengths, limitations and goals.
Communicates/collaborates with contracting providers regarding services provided.
Evaluates care, treatment and services to include active participation in interdisciplinary team meetings
Assesses for discharge and/or transfer needs and facilitates the process to ensure that continuity of care, treatment and service is maintained.
Supervision of home health aide assigned for the implementation of the patient’s plan of care.
Follows policies and procedures in the assessment, planning, intervention, evaluation and documentation of patient and family care.
Performs clinical duties within the nursing scope of practice.
Documents in electronic record within stated standards provides; complete and accurate supporting documentation.
Participates in the agency performance improvement program.
Participates in the surveillance, prevention and control of infection.
Participates in environmental safety and equipment management procedures.
Utilizes information management to support decision making to improve patient outcomes, improve health care documentation, assure patient safety and improve performance in patient care, treatment and services.
Completes annual mandatory education requirements.
Develops partnerships within the community and educates community members and healthcare providers about Midland Care services
Provides education related to hospice to staff in alternate care settings (nursing homes, hospitals, assisted-living facilities, etc.)