RN Case Manager
DUTIES AND RESPONSIBILITIES:
Operates under the director of the Clinical Director and under the Medical Director’s orders.
Responsible for identifying and coordinating patient/family care to support terminally ill patients and
families in home, skilled nursing facility or residential care facility. Frequency of patient / family contacts
will be at the discretion of the Case Manager and his/her assessment of need, but will be a minimum of
once per week. The Case Manager endeavors to utilize teaching, assessment, and intervention skills to
provide comfort care and maximize the quality of life for the patients and families.
Depending on the acuity of the patient, the Case Manager is expected to make 4-5 visits per week with
documentation. Case load can be up to 10-16 patients for 40 hrs/week. May include additional hours based on patient requirements.
1. Assess home care needs, being aware of the physical, emotional, and spiritual aspects and
gather data on social, economic and cultural factors which may influence health, well-being and
quality of life.
2. Assist patients, family members or other clients with concern and empathy; respect confidentially and
privacy and communicate in a courteous and respectful manner.
3. Provide direct care to patients as prescribed in the Interdisciplinary Plan of Care in order to maintain the
highest level of comfort and quality of life and assuming primary responsibility for case management.
4. Evaluate and perform ongoing assessment and revise initial written plan of care with Interdisciplinary
collaboration weekly or as the needs and conditions of the patient/family change.
5. Authorize, coordinate and supervise care, as prescribed in the Interdisciplinary Plan of Care, with contracted
vendors in order to meet the needs of the patient.
6. Document accurate and ongoing assessment of patient status via a variety of mediums of communication
(verbal, written, email, computer documents and databases). Document patient care reflecting nursing
interventions, patient response to care, patient needs, problems, capabilities, limitations, and progress
toward goals. Documentation includes evidence of appropriate patient/significant other teaching, and the
understanding of these instructions is noted in the medical record. Maintain up-to-date charts and records
on patient care and regular communication with the patient’s physician regarding changes in the patient’s
plan of care.
7. Investigate and follow through on unusual orders or requests for service or information.
8. Perform blood / Urine draws, if required.
9. Participate in the agency’s on-call rotation as prescribed by the needs of the agency to provide nursing
service to clients when required outside office hours.
10. Be available, when possible, to meet a patient/family's need for continuous care in time of crisis.
11. Coordinate community resources and other agency disciplines participating in patient care.
12. Minimize non-productive time and fill slow periods with assigned activities that will enable you to prepare to meet the future needs of the agency.
13. Supervise and maintain ongoing effective communication with other hospice personnel involved with patient
care. This may involve formal and informal team meetings in addition to IDT.
14. Knowledge of and availability to perform patient intakes and information visits as needed including
explanation of the hospice benefit/Medicare, complete physical assessment, completion of all pertinent
paperwork, and communication of new patient status to the Hospice Team.
15. Knowledge and availability to handle patient information calls and overflow of intake/Triage calls.
16. Provide bereavement resources to the family as appropriate.
17. Participate in hospice and community health programs as requested to promote the growth and
understanding of the hospice concept.
18. Participation in agency functions including attendance at Open Forms, Training and attending
NDHH sponsored in-services when requested.
19. Establish HHA plan of care as well as indirectly and directly supervising the plan of care per regulations.
20. Perform as a member of the New Dawn Health and Hospice team as a whole and participate in the Total Quality Management philosophy of the agency.
21. Performs other duties as assigned consistent with skills and training and the mission and goals of the
agency.