Position Summary:
The Home Health Case Manager is responsible to ensure provision of professional nursing care to patients including assessment direct physical care evaluation documentation teaching and counseling with patients in their homes. Evaluates patient responses to care and progress towards outcomes. Assists other personnel providing delegated aspects of care. Demonstrates knowledge of and delivers care in accordance to the Kansas Nurse Practice Act. Functions as a member of the interdisciplinary team.
Key Responsibilities/Essential Functions:
Other duties may be assigned. Regular and reliable attendance is an essential function of the job.
· Patients are opened within 48 hours of the date of referral or release from hospital or as the doctor orders.
· Demonstrates the ability to assess and evaluate data including: comprehensive patient/family centered assessment reassessments and discharge visits in accordance with standards of care for home health; systematic and ongoing physical assessment based on patient/family diagnoses/problem list; diagnostic tests results and other clinical information;response to medical and/or nursing care/treatment; behavioral responses; developmental/age appropriate needs; cultural/spiritual responses/needs; educational needs.
· Communicates with doctor after initial visit with plan of care and any needed or changed orders.
· Anticipates recognizes reports and responds to changes in patient condition.
· Demonstrates patient/family focus in the provision of care adhering to standards including: implements medical and nursing care interventions for specific patients/families according to nursing care standards; utilizes critical thinking to evaluate the appropriateness and effectiveness of care; assists patients and families to integrate the impact of illness and recovery into their lifestyles through patient/family education discharge planning appropriate referrals or other identified interventions; creates and maintains a climate for healing and recovery.
· Collaborates with multidisciplinary care providers in meeting patient care needs.
· Actively participates in the identification of problems/issues or concerns that impede the delivery of quality care to patients and families.
· Retains accountability for the completeness of the medical record related to the provision of nursing care and interdisciplinary communication.
· Recognizes the importance of verbal and nonverbal communication in all patient/family care activities and interactions with interdisciplinary team members.
· Participates in weekly case conference in a dynamic process of questioning and generating creative ideas to improve patient/family care and outcomes.
· Participates in peer review as appropriate.
· Develops a clinical knowledge base for populations served.
· Participates in interactions aimed at improving the quality of work life improved customer service streamline care and lower costs.
· Supports a work environment that is highly supportive of a professional practice role including accepting preceptor responsibilities for new staff members and affiliating students.
· Provides advocacy protection and support for patient rights family involvement and patient/family decision making.
· Recognizes the importance of verbal and nonverbal communication in all patient/family care activities and interactions with interdisciplinary team members.
· Promotes team work through collaboration positive communication and role modeling respecting the individuality of each patient/family and fellow staff members.
· Supports the management team in establishing and implementing goals of the unit including CQI activities staff meetings performing unit related tasks as requested and by increased awareness of own responsibility to help contain costs.
· Follows home health and OSHA standards policies procedures in the performance of all job duties to ensure a safe work environment.
· Completes documentation requirements as mandated by state and federal regulations The Joint Commission standards and agency policy including oasis surveys and 485 forms.
Management Responsibilities:
Performs supervisory visits on HHA/LPNs as directed by Medicare and state guidelines.
Qualifications:
Education and/or Experience
· A.D.N. or BSN from an accredited college or university, or diploma in nursing. BSN desired. Two years or more of hospital experience or 1 year of home health experience.
Behavioral Skills
· A personal presence which is characterized by a sense of honesty, integrity and caring with the ability to inspire and motivate others to promote the philosophy, mission, vision, goals and values of Via Christi Health System.
Certificates, Licenses, Registrations
· Graduate of an accredited School of Nursing. Current RN license for State of Kansas. Unit specific certifications and competencies.
Physical Requirements
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
· While performing the duties of this job, the employee is regularly required to stand; walk; sit; use hands to finger, handle or feel; reach with hands and arms; climb or balance; stoop, knee, crouch or crawl; talk or hear and taste or smell. The employee must regularly lift and/or move up to 50 pounds, frequently lift and/or move up to 100 pounds, and occasionally lift and/or move more than 100 pounds with another person. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.
Working Conditions
· While performing the duties of this job, the employee is frequently exposed to outside weather conditions and patients' homes that are hot/cold and cluttered/dirty. The noise level in the work environment is usually moderate.
