Registered Nurse Case Manager (Future Need)

Reports To: Director of Clinical Services About Luminary Hospice: At Luminary Hospice, we are a mission-driven organization that empowers our team members to shape our culture in order to allow them to provide the highest quality support to patients and families throughout their entire end-of-life journey. Our mission is to deliver personalized care that radiates compassion and preserves dignity for all that we are honored to serve on their end-of-life journey. We are centered on caring for the whole person – with expert medical care, pain management as well as emotional and spiritual support along with resources, information, and emotional support for families and caregivers.

About The Role

: The Registered Nurse Case Manager plans, organizes, and directs hospice care and is experienced in nursing, with an emphasis on community health education/experience. The professional nurse builds from the resources of the community to plan and direct services to meet the needs of individuals and families within their homes and communities.

Responsibilities

: Patient Care Completes an initial, comprehensive, and ongoing comprehensive assessment of the patient and family to determine hospice needs. Provides a complete physical assessment and history of current and previous illness(es). Provides professional nursing care by utilizing all elements of the nursing process.

Assesses and evaluates patient’s status by: Writing and initiating a plan of care Regularly re-evaluating patient and family/caregiver needs Participating in revising the plan of care as necessary Initiates the plan of care and makes necessary revisions as patient status and needs change. Uses health assessment data to determine nursing diagnosis. Develops a care plan that establishes goals, based on nursing diagnosis and incorporates palliative nursing actions.

Includes the patient and the family in the planning process. Initiates appropriate preventive and rehabilitative nursing procedures. Administers medications and treatments as prescribed by the physician in the physician’s plan of care.

Counsels the patient and family in meeting nursing and related needs. Provides health care instructions to the patient as appropriate per assessment and plan. Assists the patient with the activities of daily living and facilitates the patient’s efforts toward self-sufficiency and optional comfort care.

Acts as Case Manager when assigned by Clinical Supervisor and assumes responsibility for coordinating patient care for assigned caseload. Communication Completes, maintains, and submits accurate and relevant clinical notes regarding the patient’s condition and care given. Records pain/symptom management changes/outcomes as appropriate.

Communicates with the physician regarding the patient’s needs and reports changes in the patient’s condition; obtains/receives physicians’ orders as required. Communicate with community health-related persons to coordinate the care plan. Teach the patient and family/caregiver self-care techniques as appropriate.

Provides medication, diet, and other instructions as ordered by the physician and recognizes and utilizes opportunities for health counseling with patients and families/caregivers. Works in concert with the interdisciplinary group. Provides and maintains a safe environment for the patient.

Assists the patient's family/caregiver and other team members in providing continuity of care. Works in cooperation with the family/caregiver and hospice interdisciplinary group to meet the emotional needs of the patient and family/caregiver. Attends interdisciplinary group meetings.

Additional Duties Participates in on-call duties as defined by the on-call policy. Ensures that arrangements for equipment and other necessary items and services are available.

when required.