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Job Description At Community Hospice & Health Services and its affiliates, Community Hospice & Health Services Foundation, and CHI Management, Inc. (herein referred to collectively as “CHHS”) you will find a family-based and compassionate work environment. Our goal is to provide a wonderful work experience that allows our employees to thrive by feeling engaged and fulfilled each day. CHHS is the largest and oldest nonprofit hospice and community-based palliative care provider in the Central Valley. We are proud to indicate that CHHS has been supporting and providing compassionate and quality services to our community since 1979. Our mission is to embrace individuals and families facing life-changing journeys, enhancing quality of life for all. CHHS is accredited by CHAP (Community Health Accredited Program). SUMMARY: As a member of the interdisciplinary team, the RN Case Manager (RNCM) works under the general direction of the Patient Care Manager (PCM). The RNCM provides skilled nursing assessment, care planning, and interventions in accordance with plan of care and Community Hospice’s policies and procedures in order to maximize the comfort and quality of life of hospice patients and families. The RNCM coordinates communication between members of the Interdisciplinary Team, including patient/family and attending physician. RESPONSIBILITIES: 1. Admissions of new patients, which includes assessment, planning, implementation, and evaluation phases of the nursing process, evaluations of patient appropriateness for hospice services, and consultations to explain hospice services, as requested by the Patient Care Manager. Standard: Visit will be made on day requested. Documentation will be completed on the same day as visit. 1. Perform scheduled home visits to assess needs; teach caregivers pain management, symptom control and patient care skills; and provide physical, emotional and spiritual support to the patient/family. Standard: Home visits made according to plan of care. Visit frequencies reflect patient/family needs and current condition and are updated as needed. Documentation completed and submitted within 24 hours of visit. 1. Maintain regular communication with interdisciplinary team regarding patient status or any unusual or problematic patient/family issues. Standard: Patient’s status changes must be reported to Triage Nurse by 4:30 p.m. and to other team members immediately on regular business days or by 9:00 A.M. on the day following a weekend or holiday. 1. Initiate communication with attending physicians and other team members and other community agencies as needed to coordinate plan of care and use of resources for patient/family. Standard: Communications with other team members will be done within 24 hours of patient contact and documented in the clinical record unless patient/family needs require immediate attention by the other team members. Patient falls and other safety issues, patient discomforts and changes in status requiring MD orders, and abuse/neglect issues will be communicated to the attending physician at the time of the visit. 1. Maintain up-to-date patient records so that problems, goals, and interventions are accurately and clearly documented and changes in the plan of care are reflected as they occur. Standard: Visit documentation clearly indicates following the plan of care. Supplemental orders/updates to the plan of care will be completed and submitted to Medical Records within 24 hours. Medication lists are to be reviewed at a minimum of weekly to ensure accuracy. 1. Attend regularly scheduled Interdisciplinary Team Meetings to review patient/family needs, problem solve and cover unique issues, share professional support and exchange feedback aimed toward enhancing professional growth. Standard: Attendance at and preparation for Interdisciplinary Team Meetings is required. RNCMs must be prepared to discuss changes to the plan of care, recertification’s, and changes in status of patients. Interdisciplinary Team Meetings are not meant to take the place of routine communication between team members. 1. Accept responsibility for coordinating physical care of the patient, including Home Health Aide and Licensed Vocational Nurse assignment and supervision, teaching primary caregivers and employed caregivers, teaching facility staff, or by providing direct care as appropriate. Standard: Provide all aspects of patient family teaching. Update the Home Health Aide assignment as needed. Supervise Home Health Aide as required by Community Hospice policies and procedures. Coordinate changes in patient level of care/residence changes/status changes. 1. Assure continuity of care for patient in all settings. Standard: Coordinate transfers to inpatient, respite, and alternative living situations. Create joint plan of care where needed. Participate in joint care plan meetings where needed. Participate in providing inservices to staff in contracted facilities, as assigned. 1. Share in providing 24 hour, 7 day week and holiday coverage to patient/families. Standard: Take rotation for on-call time and be responsible to make any changes among the other staff nurses. 1. Attend death events and provide appropriate support at time of death. Standard: Attends death events and participates in bereavement as requested. 1. Participate in Community Hospice education of students and community healthcare professionals and participate in the orientation of new employees. Standard: Participates in Community Hospice ride-a-long program and other student programs as requested by the Clinical Educator. Acts as a preceptor to new employees, as assigned. 1. Participate in agency Quality Improvement process to improve level of services provided to Community Hospice patients and families. Standard: Completes audit requests within 5 business days of receipt. Submits Quality Assurance Alert forms to report quality issues. Submits Hospice Acquired Infection Control Assessment Form. Participates in quality improvement projects as assigned. 1. Participate in inservices, workshops, and clinical meetings to promote professional growth and understanding of hospice care. Standard: Attendance at 80% of all mandatory inservices and meetings, designated as RNCM appropriate, provided by agency. Completes all required inservices. 1. Follow all Community Hospice policies and procedures including, but not limited to, safety, infection control, privacy and confidentiality, and HIPAA. Standard: 100% Compliance 1. Must maintain RN license in accordance with federal, state and local laws, and must act only within the scope of his or her state license. All personnel qualifications must be kept current at all times. Standard 100% Compliance OTHER FUNCTIONS: 1. Maintain a professional appearance of self and working area; exhibit appropriate behavior with guests and clients, i.e., courteous, thoughtful and professional at all times., 2. Other duties as assigned, including work in other areas to cover absences or relief to equalize peak work periods or otherwise meet the needs of the organization., 3. Responsible for establishing and maintaining a safe environment for patients/families, and a safe working environment for self and coworkers., 4. Performs job duties and interacts with patients/families, Community Hospice staff, and community members in a courteous and professional manner., 5. Maintains all required confidentiality and privacy requirements of both the organization and the regulatory agencies that have oversight of and for Community Hospice. SUCCESS FACTORS: 1. Maturity and ability to cope with the demands of the job., 2. Empathetic attitude toward the care and needs of the terminal patient and their family., 3. Able to recognize and follow healthy emotional boundaries., 4. Ability to work in a dynamic, rapidly changing environment., 5. Excellent listening, verbal, and written communication skills., 6. Ability to follow written directions and to provide accurate and timely documentation., 7. Ability to work as a member of an interdisciplinary team., 8. Demonstrated ability to assess and respond to needs of patients/families in varied settings., 9. Able to cope with patient/family emotional environment and provide crisis intervention. QUALIFICATIONS: 1. Graduation from an accredited school of nursing. BSN preferred., 2. At least one year recent experience within the last three years as a professional nurse or BSN from a program accredited by the National League of Nursing., 3. Possession of a current license to practice as a registered nurse in the State of California., 4. Timely renewal required., 5. Possession of a valid California driver’s license and current automobile insurance. Timely renewal required., 6. CHPN preferred., 7. Possesses and maintains current CPR certification. WORK ENVIRONMENT: The main environment for this position is in the patients' homes, which vary in levels of cleanliness, accessibility, and climate control. The employee may be exposed to virus, disease and infection from patients. The employee may experience situations, with emotionally disturbed, substance abuse, serious illness, and deceased patients. While performing the duties of this position, the employee will travel by automobile and is exposed to changing weather conditions. WORK SCHEDULE: Position is regular full-time required to work a regularly scheduled 40-hour workweek, with overtime required to meet patient needs. Position may also require rotating weekends and holidays. 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