Home Health RN Case Manager
Primary functions are to provide nursing care for clients of all ages in their place of residence, coordinate care with the interdisciplinary team, patient/family, and referring agency; and assume the responsibility for coordination of care. Essential Functions: Initial and ongoing comprehensive assessments of the impact of the terminal disease on the patient's physical, functional, psychosocial, and environmental needs and ADLs, i.e., the risk for grief, cultural and spiritual, verbal and non-verbal. Implement the individualized POC and recommend revisions to the plan as necessary. Consulting with and educating the patient and family regarding the disease process, self-care techniques, end-of-life care, nutrition, and dietary needs. Providing training to other staff as needed. Initiating appropriate preventive and rehabilitative nursing procedures. Preparing clinical and progress notes that demonstrate progress toward established goals. Coordinating all patient and family services and prioritization of needs with the members of the IDT. Informing physician and other personnel of changes in the patient’s needs and outcomes of the intervention, while evaluating patient/family response to care. Determining scope and frequency of services needed based on acuity and patient/family needs. Assessing the ability of the caregiver to meet the patient’s immediate needs upon admission and throughout care. Evaluating own needs for support and using identified systems to meet the need