Under the leadership of the Director, Home Health, the Home Health Case Manager II is an active member of the Home Health team that delivers professional end-of-life care and services consistent with the strategic vision, goals, philosophy and direction of the Home Health Department and CRHS. The Home Health Case Manager II reviews patient and family needs and develops age-appropriate and culturally sensitive nursing care for patients of all ages in their homes. The Home Health Case Manager II formulates an appropriate nursing plan of care with goals mutually set by the RN and the patient and/or caregiver. The Home Health Case Manager II formulates an appropriate and safe aide plan of care and supervises the aide every 14 days in the patient's home and assesses the effectiveness of interventions and education to the patient and his/her family.
Requires a Bachelor's degree in nursing.
Requires one to two years of work-related experience or any equivalent combination of education, training and experience.
- Licensure, Registrations & Certifications:
Requires current state license as a Registered Nurse.
Maintains a current certification in Basic Life Support (If BLS verification is not current upon hire, it must be obtained within three (3) months of hire.)
Maintains a current valid Driver's License and proof of minimum automobile insurance.
Requires a current valid driver's license. A Motor Vehicle Report is required upon hire and reviewed annually.
Essential Job Responsibilities:
- Assesses patient and develops plan of care, establishes mutually agreed upon goals with the patient, caregivers, and/or family members.
- Develops an appropriate and safe aide plan of care based on the patient's medical, psychosocial and emotional needs and environmental and financial factors that affect the current and future patient status.
- Supervises the care rendered by the CNA and LPN within the patient's home and ensures compliance with the established plan of care.
- Renders professional nursing care, including the administration of medicine and drugs, monitoring IV's, performing venipuncture, inserting intravenous catheters, , performing the more complex as well as routine treatments as prescribed by the physician or as indicated by the resident's condition.
- Obtains referrals for other skilled services as indicated.
- Provides emotional support and education to patients and their families.
- Ensures the compliance with established infection control procedures by all caregivers and/or family members.
- Ensures the accurate documentation of assessments, care plans, goals, medications, communications, and interventions.
- Reviews and revises the plan of care every 60 days and as needed.
- Reports significant changes in the patient's condition promptly to the attending physician.
- Utilizes nursing skills to independently administer intermittent safe, timely and effective nursing care and therapeutic treatment in the patient's home as ordered by the physician.
- Evaluates and documents the effectiveness of the plan of care as developed by all members of the interdisciplinary team working with the patient.
- Actively participates in Home Health interdisciplinary group meetings and home health case conferences.
- Submits completed documentation in accordance with established standards for timeliness and accuracy.
- Complies with Home Health quality, satisfaction and regulatory compliance standards to ensure they are either met or exceeded.
- Works continually to identify new approaches that improve the quality and timeliness of Home Health care.
- Follows all Hospice policies and procedures and ensures compliance with all federal and state laws, regulations and JCAHO requirements.
- Mentors new employees as requested.
- Completes all required professional education including continuing nursing education hours and mandatory in-services to maintain professional licensure.
- Performs other related job duties as assigned.
Standards of Performance:
- Prepares, completes and submits clinical documentation for all assigned cases on the day of the visit (unless preapproved for submission the following morning) as measured by log and chart audits.
- Develops patient care plan, sets mutual goals with the patient, develops aide care plan as measured by chart audits and observation.
- Reports and documents significant changes and events to the physician as measured by chart audits.
- Obtains orders for other disciplines as needed by the patient. Gives and documents reports to the other disciplines as measured through chart audits and staff observation.
- Provides interdisciplinary collaboration as measured by attendance and active participation in case conferences and interdisciplinary meetings, documentation of communications, and appropriate revision of plan of care based on feedback from the other disciplines participating in the patient's care.
- Completes reassessments, visit logs, nursing notes, and summaries on time, as measured through chart audits.
- Provides safe care following infection control protocols, as measured through observation and supervisory visits.
- Provides effective education to the patient and/or caregiver, and provides nursing interventions to help the patient and caregiver reach their goals, as measured by chart audits and outcomes.
- Participates in performance improvement activities and chart audits as measured by documentation and submission of PI data as assigned.
- Demonstrates positive interpersonal skills when communicating with patients, families, coworkers and physicians, as measured by observation, and through patient and family satisfaction survey results.
- Participates in education as required through mandatory in-services, acquisition of continuing nursing education, and department in-services as measured by education and attendance records, and maintenance of professional licensure.
- Demonstrates adherence to CRHS Standards of Behavior as measured by peer, supervisor and patient observations.
- Demonstrates reliability as measured by compliance with CRHS Time and Attendance policies.
- Demonstrates professional conduct by maintaining strict confidentiality, as measured by valid complaints given to the supervisor or director.
- Demonstrates adherence with infection control procedures as measured through direct observation.
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