Capital Caring Health

Manager

• Assess and identify patient/family needs using the nursing process
• Coordinate individualized Plans of Care with the Interdisciplinary Team (IDT)
• Provide clinical, palliative, supportive, and direct patient/family care in the home
• Provide telephone reassurance and arrange in-person visits when needed
• Resolve complex situations using appropriate support and expert resources
• Document patient/family contacts and care in the EMR
• Complete initial and semi-annual assessments for Company services
• Explain services and address patient/family questions, fears, limitations, and needs
• Initiate skilled nursing interventions to prevent complications, alleviate symptoms, and maximize comfort
• Obtain physician orders and complete required documentation
• Represent the Company at assigned facilities and facilitate referrals across service lines
• Communicate clinical information using SBAR and collaborate frequently with IDT members
• Develop relationships with facility case managers and physicians
• Manage direct care incorporating psychosocial, spiritual, cultural, physical, and biological components
• Educate patients, families, caregivers, and health professionals about disease progression, palliative interventions, caregiving, dying process, and safety
• Conduct home visits for safety, medication, nutrition, DME compliance, and community living assessments
• Report patient condition changes to IDT and other health professionals
• Participate in hospice referral/admission evaluations and daily IDT collaboration meetings
• Present oral and written reports to the IDT
• Supervise care provided by Community Health Workers and Home Health Aides as requested
• Report to a company-designated location during emergencies and remain overnight when required
• Perform other assigned duties

Hospice RN Case Manager