Major Responsibilities:

Responsible for identifying and coordinating patient/family care to support terminally ill patients and families in all hospice settings. Frequency of patient / family contacts will be at the discretion of the Case Manager and his/her assessment of need, but will be a minimum of every 15 days. The Case Manager utilizes teaching, assessment, and intervention skills to provide comfort care at end of life and maximize the quality of life for the patients and families.

Educates patients and families regarding disease processes and trajectory, disease management, hospice philosophies, signs and symptoms of decline and end of life. Updates the primary physician as indicated and according to agency, accreditation, state and federal requirements.

Responsible for continuous review of all aspects of every patient of her/his caseload to include appropriate utilization of services and the appropriate hospice level of care criteria are met. Makes referrals to other team members as appropriate.

Administers medication and treatments as prescribed by the physician.

 Leads the interdisciplinary care group (IDG) specific to each patient and family on their caseload.  Working within the IDG to develop, revise, and implement the patient’s Plan of Care. Coordinates all services and collaborates with members of the interdisciplinary team to provide consistent patient care. Arranges for and/or recommends equipment, medical supplies and other necessary items and services as indicated.

Enters, completes and updates documentation in the electronic health record as required according to agency/department standards and policies, accreditation, state and federal guidelines.

Documentation accurately records the patient’s experience with a combination of assessments and narrative   .

Provides on-going assessment of patient response to treatments, medications and teaching while making appropriate changes in interventions and follow-up to meet patient needs.  Updates and revises POC as indicated with supportive documentation to changes. Communicates problems and changes in condition to physicians, supervisor and other members of the IDG. Enters verbal orders from the physician or APN into the Electronic Health Record.

Supervises and performs Home Health Aide and licensed practical nurse supervisory visits according to agency standards. Instructs paraprofessional staff on a timely basis and in accordance with agency, state and federal regulations.

Facilitates the discharge planning process according to agency standards and utilizes interagency/system and community resources to assure continuity of care after discharge.

WI ONLY: May conduct OASIS assessments for Palliative Care patient and establish and update the plan of care. May conduct hospice initial and comprehensive assessments and establish and update the plan of care. Ensures continued skilled nursing/home bound criteria are met.  Initiates appropriate preventive and rehabilitative nursing procedures.

Utilizes proper body mechanics, assistive devices and safety techniques when performing various patient positioning/repositioning and transporting duties, which require lifting, and pushing/pulling. Orients and mentors new staff as requested.

Must be able to demonstrate knowledge and skills necessary to provide care appropriate to the age of the patients served.  Must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify each patient's requirements relative to his/her age-specific needs, and to provide the care needed as described in the department's policies and procedures.  Age-specific information is developed further in the departmental job standards.

Licensure, Registration and/or Certification Required:

Registered Nurse license issued by the state in which the team member practices, and

Basic Life Support (BLS) for Healthcare Providers certification issued by the American Heart Association (AHA) needs to be obtained upon hire unless department leader has determined it is not required, and

A valid driver’s license issued by the Division of Motor Vehicles.

Education Required:

Completion of an accredited or approved program in Nursing.

Experience Required:

Typically requires 1-2 years of experience in nursing that includes experiences in home health, hospice, medical/surgical, long term care, emergency care/ICU or oncology or similar related experience.  

Knowledge, Skills & Abilities Required:

Competent in the principles of deformity prevention, normal range of motion, body mechanics and body alignment; and fundamental principles of human behavior and an understanding of the effects of stress upon individuals and groups.

Excellent awareness and perception skills, for the purpose of assessing a patient's needs, concerns and to recognize changes in their health condition.

Excellent communication and interpersonal skills.

Excellent decision making and critical thinking skills, with the ability to work independently and make sound judgments.

Excellent prioritization and organizational skills.

Physical Requirements and Working Conditions:

Must be able to:
-  Lift up to 50 lbs. from floor to waist.
-  Lift up to 20 lbs. over the head.
-  Carry up to 40 lbs. a reasonable distance.

Must be able to:
-  Push/pull with 30 lbs. of force.
Perform a sliding transfer of 150 lbs. with a second person present.

Must be able to work safely with people of various sizes and weight, with diverse and complex medical conditions and physical limitations. 

Must have the physical agility and stamina to move about in confined spaces, including bending, kneeling, squatting and occasionally reaching one or both arms over the head for long periods of time.

Will be exposed to the following hazards on a frequent basis: mechanical, electrical, chemical, blood and body fluids.  Will be required to wear protective clothing and equipment as needed. 

Must have functional speech, vision, hearing, and touch with ability to use fine-hand manipulation skills. 

Operates all equipment necessary to perform the job.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.