REGISTERED NURSE CASE MANAGER

Title: Registered Nurse Case Manager

Department: Home Care & Hospice

FLSA Status: Non-Exempt

Reports To: Director of Patient Care Services/ Clinical Manager

Summary: The registered nurse plans, organizes and directs home health care and hospice care and is experienced in nursing, with emphasis on community health education/experience. The professional nurse builds from the source of the community to plan and direct services to meet the needs of individual and families within their homes and communities.

Essential Functions:

Home Health:
• Assesses and identifies patient and/or family needs and for providing supportive care (physical and emotional) in accordance with physician's orders, plan of care, and Self-Help Home Care & Hospice policies and procedures.
• Assumes responsibility for patient caseload, including the assessing, planning, implementing and evaluating phases of the nursing process towards desired outcomes.
• Develops, evaluates, and revise patient's individualized plan of care in collaboration with Director or Patient Care Services, Medical Director, other members of the Inter-Disciplinary Group, and patient's primary care physician.
• Maintains up-to-date patient records so that problems, plans, actions and goals are accurately and clearly stated and changes are reflected as they occur.
• Assesses all aspects of the patient's pain and develops an individualized pain management plan.
• Anticipates, prevents, and treats undesirable symptoms or secondary symptoms.
• Coordinates physical care of the patient by teaching and/or training patients, primary caregivers, volunteers, employed caregivers, and by providing direct care as appropriate.
• Coordinates care for patient with staff of SNF and RCFE/Board and Care facilities.
• Coordinates and manages patient care with awareness of insurance benefits, necessary authorizations and cost containment.
• Attends Interdisciplinary conferences to facilitate discussion of issues relating to patient care.
• Informs the Supervisor of unusual or potentially problematic patient and family issues.
• Practice team leading nursing to Licensed Vocational Nurses in the provision and coordination of care in accordance to rules and regulations.

Hospice:
• Completes an initial, comprehensive and ongoing comprehensive assessment of patient and family to determine hospice needs. Provides a complete physical assessment and history of current and previous illness(es).
• Assesses and evaluates patient's status by:

A. Writing and initiating plan of care

B. Regularly re-evaluating patient and family/caregiver needs

C. Participating in revising the plan of care as necessary
• Initiates the plan of care and makes necessary revisions as patient status and needs change.
• Uses health assessment data to determine nursing diagnosis.
• Develops a care plan that establishes goals, based on nursing diagnosis and incorporates palliative nursing actions. Includes the patient and the family in the planning process.
• Initiates appropriate preventive and rehabilitative nursing procedures. Administers medications and treatments as prescribed by the physician in the physician's plan of care.
• Counsels the patient and family in meeting nursing and related needs.
• Provides professional nursing care by utilizing all elements of nursing process.
• Provides health care instructions to the patient as appropriate per assessment and plan.
• Assists the patient with the activities of daily living and facilitates the patient's efforts toward self-sufficiency and optional comfort care.
• Acts as Case Manager when assigned by Clinical Supervisor and assumes responsibility to coordinate patient care for assigned caseload.
• Obtains data on physical, psychological, social and spiritual & cultural belief factors that may influence patient health status and incorporates that data into the plan of care. Monitors and revises the plan of care, as appropriate, to changing patient and family needs.
• Maintains the dignity, confidentiality, and privacy of the dying patient.
• Provides holistic, family-centered care to improve the patient's quality of life.
• Identifies and addresses signs of actively dying patients.
• Coordinates patient care plan of declining patients with after hours on call staff.

Communication:
• Attends departmental meetings and participates in agency and community programs as requested to promote professional growth and understanding of home health and/or hospice care.
• Maintains accurate and timely documentation of all care delivered and ensures compliance with local, state, federal statutes and regulations.

A. Completes, maintains and submits accurate and relevant clinical notes regarding patient's condition and care given. Records pain/symptom management changes/outcomes as appropriate.

B. Completes patient-related documentation within 24 to 48 hours of the shift worked.
• Communicates with the physician, Home Care and Hospice team members, and other agencies as needed regarding the patient's needs and reports changes in the patient's condition; obtains/receives physicians' orders as required to coordinate optimal care and use of community resources for the patient and/or family.
• Communicates with community health related persons to coordinate the care plan.
• Teaches the patient and family/caregiver self-care techniques as appropriate. Provides medication, diet and other instructions as ordered by the physician and recognizes and utilizes opportunities for health counseling with patients and families/caregivers. Works in concert with the interdisciplinary group.
• Assists the patient and family/caregiver and other team members in providing continuity of care.
• Works in cooperation with the family/caregiver and hospice interdisciplinary group to meet the emotional needs of the patient and family/caregiver.

Additional Duties:
• Provides and maintains a safe environment for the patient.
• Participates in on-call duties as defined by the on-call policy.
• Ensures that arrangements for equipment and other necessary items and services are available.
• Supervises ancillary personnel and delegates responsibilities when required.
• Assumes responsibility for personal growth and development and maintains and upgrades professional knowledge and practice skills through attendance and participation in continuing education and in-service classes.
• Fulfills the obligation of requested and/or accepted case assignments.
• Actively participates in quality assessment performance improvement teams and activities.
• Supervises certified home health aides and documents their plan of care as required by Medicare home health and hospice COP's and California Title 22.
• Attends interdisciplinary group meetings. Participates in agency's orientation and in-service training programs for professional staff, as well as quality assurance and performance improvement activities.
• Ensures SHE and HCH policies are followed in the performance of duties.
• Performs other duties as assigned.

Qualifications:
• Current California Licensed Registered Nurse.
• Registered nurses shall have a minimum of (a) one (1) year of experience as a professional nurse within the last three (3) years; OR have a baccalaureate degree in nursing from a program accredited by the National League of Nursing and a current RN license. Minimum of two (2) years' experience, at least one of which is in the area of public health, home care, or hospice nursing is preferred.
• Management experience not required. Responsible for supervising hospice aides.
• Ability to work both independently and as part of an interdisciplinary team.
• Current CPR certification.
• Must pass health screening for TB clearance, physical examination, and background check.
• Knowledgeable of OASIS.
• Bilingual in English and Chinese is a plus.
• Excellent observation, verbal and written communication skills, problem solving skills, basic math skills; nursing skills per competency checklist.
• Prolonged or considerable walking or standing. Able to lift, position and/or transfer patients. Able to lift supplies and equipment. Considerable reaching, stooping bending, kneeling and/or crouching. Visual acuity and hearing to perform required nursing skills.
• Must be able to travel via public transportation or personal/department vehicle for performance of job duties. If driving, must have and maintain a valid CA driver license, satisfactory driving record, and auto insurance coverage as specified in Self-Help's policy.

Self-Help for the Elderly is an Equal Employment Opportunity/Affirmation Action Employer and we welcome diversity in the workplace. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, age, national origin, sexual orientation, disability, protected veteran status or any other characteristics protected by law. We participate in E-Verify.

Qualified applicants with criminal history will be considered for employment in accordance with the San Francisco Fair Chance Ordinance.

We may provide reasonable accommodations to applicants with disabilities. If you need a reasonable accommodation for any part of the application or hiring process, please call (415) 677-7600 for special assistance.

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