- Patient and Family Assessments Assess patient's and family's physical, pain, psychosocial, emotional, spiritual, environmental and educational needs as outlined by the plan of care (POC). Collect data from the patient, family, significant other or other members of the interdisciplinary team and other health care professionals. Identify, interpret, and document assessment data collected in the nursing interview, physical assessment and other health data. Document and report significant changes in condition or unusual incidents to appropriate IDT member such as client abuse/neglect, suicidal intent, harmful coping mechanisms or violence, etc. Collaborate with IDT and primary care provider to create HES for determination of hospice eligibility.
- Patient Visits Respond to patient and family needs or change in condition or need for acute patient intervention. Provide interventions, treatments, and pain management to patient and family to meet needs. Evaluate the effectiveness of pain management or other intervention and adjust to meet needs. Provide patient and family education on pain, symptom management, end of life, etc. Evaluate the effectiveness of education and adjust to meet needs.
- Plan of Care Formulate, implement, and revise individualized POC in collaboration with Interdisciplinary Team (IDT), patient, and family. The POC to include goals, pain management, interventions, education, discharge plan, etc. Develop reasonable and achievable outcome measures and establish priorities in the planning and provision of care. Read, understand, and follow the plan of care. Document interventions, outcomes, and changes in patient condition in electronic health record (EHR). Delegate visits to appropriate disciplines and manage visit sets. Oversee work of Certified Nursing Assistants (CNA) and Licensed Practical Nurses (LPN).
- Miscellaneous Participate in meetings to plan and evaluate patient/family services. Precept new staff and students.
- ADN or BSN required
- Current, unrestricted Registered Nursing License in state of employment
- One-year nursing experience, preferred
- Valid driver's license, auto insurance, and access to a reliable vehicle
- Must be at least 18 years of age
- Ability to develop, maintain, and apply knowledge of hospice and end of life process
- Ability to maintain professional boundaries with patients, families and co-workers
- Ability to create and follow plans of care, and patient, family, and clinical staff directions
- Basic Microsoft Office skills
- Intermediate electronic health records skills; Epic preferred
- Ability to work effectively and cooperatively with others
- Ability to communicate effectively verbally and in writing
- Ability to be flexible in time and task to meet organizational needs
- Ability to maintain confidentiality about patients, families, caregivers, staff, donors, and organizational intellectual property
- Ability to use proper body mechanics, safe patient handling, and standard precautions
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RN Case Manager Homecare - Oconomowoc, United States - Agrace
Description
Agrace is a nonprofit, community health care organization that is nationally recognized as a leader in the hospice industry. Well known for end-of-life care, Agrace also serves people across southern Wisconsin who are aging, seriously ill or grieving.
Agrace has a strong culture of employee engagement. In 2023, Agrace was named the #1 Top Workplace by the Wisconsin State Journal and Energage, and #79 of the top 100 companies in the country among those with an employee base of 500 to 999 workers
Hours Monday-Friday 8am-5pm Weekend Rotation Every Eighth Weekend Holiday Rotation Two Holidays/Year On Call Rotation One Weekend/Quarter Bonus Eligibility $6,000 Coverage Area Jefferson/Walworth CountyWHO YOU'LL WORK WITH (AND WHAT THEY HAVE TO SAY)
The RN Case Manager works on a collaborative interdisciplinary team including Social Workers, RNs, CNAs, Volunteer Coordinators, and Clinical Assistants.
"Management cares and offers support, nobody at the organization belittles anyone for asking questions or help. Agrace makes everyone feel valued." - Homecare Employee
HOW YOU'LL MAKE A DIFFERENCE IN THIS ROLE (ESSENTIAL FUNCTIONS)
The RNCM is responsible for patient and family satisfaction through the provision of nursing care and case management by conducting assessments, creating and updating the plan of care, providing interventions, communicating, and documenting. The RNCM provides patient and family centered care consistent with Agrace philosophy, goals, standards, regulations and policies.
YOU BRING (EXPERIENCE & QUALIFICATIONS)
Don't meet these qualifications as written? We would still love to talk about roles at Agrace:
At Agrace we are strengthened by the diverse experiences, cultures and traditions of our staff, patients, and clients.
Together, we pursue a vision of equity—in which every Agrace staff member is treated fairly, and every patient and client experiences the respectful, individualized care they need and deserve.
We foster a culture of belonging and inclusion that celebrates people's uniqueness and leads to meaningful, empathetic connections.
Agrace HospiceCare is an Equal Opportunity Employer and does not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.
RN Case Manager Homecare professionals in Oconomowoc
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Gina M Labellarte
Certified Physician Assistant