Registered Nurse Home Health Case Manager

Assumes responsibility for workload consisting of patients requiring Home Health, Infusion and Pediatric nursing, and/or Palliative and Hospice services.
Conducts initial assessment to obtain thorough physical, social and environmental data.
Establishes the plan of care in accordance with the physician orders and patient needs.
Provides direct patient care and adjusts nursing care processes as needed.
Identifies problems, modifies nursing care plan, and evaluates outcomes within an appropriate time frame.
Advises and consults with family and other personnel, as appropriate.

Provides on-going assessment of patient response to treatments and teaching and applies interventions as appropriate.
Updates and revises plan of care as indicated.

Completes documentation including visit assessment, OASIS, 485 and verbal orders accurately and promptly and within the standards.

Communicates with physicians to confirm and update patients' plan of care.
Provides status updates and ensures ongoing communication with the physician and other members of the health care team.
Facilitates the discharge planning process according to standards and utilizes resources to assure continuity of care after discharge.
Participates in developing the discharge plan with the patient/family, physician, social worker, and other staff members as appropriate.
Participates in chart audits and continuous quality improvement activities as requested.
Identifies, develops and participates in process improvement opportunities that will enhance the quality of the services provided.

Maintains and updates accurate clinical and patient records according to agency, state, and federal guidelines.

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.