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B. Assessment of Needs. After the primary MD orders services, the RN case manager shall…

1. Make an initial home visit to:

2. Present the patient/family information she gathers to the IDT.

3. Documents findings on appropriate forms.

C. Development of Care Plan. The primary RN case manager shall…

1. Establish nursing diagnosis.

2. Develop a plan of care, with goals defined by the patient/family while in the home.

3. Enter POC into the automated management information system.

4. Develop a Certified Nursing Assistant POC if needed. Make 5 copies with original signature on each and place in CNA book.

D. Implementation of Care Plan. The primary RN case manager shall…

1. Provide nursing services (treatment of symptoms, preventative measures, etc.) according to the plan of care that has been developed.

2. Make referral to other services as needed in conjunction with the social worker.

3. Teach the primary caregiver and the certified nursing assistant by role modeling, repetition, reinforcement:

4. Direct and coordinate care and services according to the care plan, maintain communication with the patient’s physician (MD), and other team members.

5. Make nursing services available on an on-going basis:

6. Provide the patient/family with information concerning the disease process, regiment of treatment, and alternative methods of care:

7. Re-evaluate each patient monthly to ascertain hospice eligibility and complete criteria. Create plan for discharge or transfer if patient is not meeting eligibility criteria. Refer to appropriate resources as needed.

8. Provide emotional support while maintaining professional boundaries:

9. Provide services at the time of death:

10. Assist with bereavement follow-up:

E. Evaluation of the Care Plan. The primary RN case manager shall…

1. Evaluate the effectiveness of nursing interventions on a regular basis and whenever changes occur in the patient/family situation.

2. Present the care plan to the IDT for review and update as changes occur in the patient’s condition, every two weeks.

3. Communicate with the MD concerning treatment orders when changes occur in the patient’s condition.

4. Evaluate patient/family for needed changes in level of care. Initiate changes according to written policy/procedure.

5. Document any changes in initial POC via verbal/telephone order and updating in the management information system.

6. Documents of telephone calls with attending physicians and discussion s with other team members.

F. Interaction as a Member of the Interdisciplinary Team. The primary RN case manager shall…

1. Initiate and coordinate communication with the team working with the patient/family.

2. Assist the Nursing Care Coordinator and/or the Volunteer Coordinator in assigning patient/family volunteers.

3. Communicate new developments to the Nursing Care Coordinator.

4. Meet regularly with the social worker to coordinate intervention.

5. Communicate with the MD, either orally or by letter, after the initial home visit, then as needed and as required by law.

6. Communicate with other nurses who might provide care in the primary RN’s absence.

7. Assist in orienting new team members.

8. Consult with other team members and make referrals to outside agencies as necessary.

9. Attend team conferences.

10. Supervise/monitor continuous care personnel according to continuous care policy/procedures.

G. Maintain Current Knowledge and Competency in Providing Care to Terminally Ill Patients and Their Families.

1. Attend continuing education classes, in-services and workshops.

2. Review current nursing literature.

Administrative Duties and Responsibilities:

A nurse case manager shall:

A. Initiate and coordinate communication with the team working with the patients assigned to her, supervising and instructing Certified Nursing Assistants and volunteers serving her patients in their homes.

B. Assist in orienting new team members.

C. Provide on-call, weekend and holiday services rotation when coverage is needed.

D. Keep patient/family records up to date and promptly com­plete all forms required by law and specified by agency policy.

E. Participates in the agency’s quality assurance process to assure nursing care is appropriate and congruent with standards.

F. Participates in continuous quality improvement processes as requested and indicated.

G. Documents services and expenditures for reimbursement purposes.

H. Cooperate with all government agencies and outside auditors.

I. Cooperates with all regulating and accrediting agencies.

J. Complies with the agency’s uniform dress code.

Qualifications:

Must be a graduate of an approved school of nursing and shall be licensed in the State of South Carolina.

A minimum of two to three years experience with home health nursing or critical care nursing experience; medical/surgical experience desired.

Knowledge, Skills, and Abilities:

A knowledge of the core care standards and rules for hospice and palliative care.

A repertoire of service-driven and patient-oriented interpersonal skills, a sincere appreciation of people.

The possession of multifaceted skills accompanied by flexibility; a knowledge that change can be difficult.

Able to recognize stress-related responses and able to develop coping mechanisms to deal with the innate stress of providing services to persons in crises.

The ability to assume responsibility for the patient and family’s care and the patient’s POC.

Self-direction and the ability to function autonomously in a non-structured atmosphere.

The desire to continue learning and being open to new information and clinical skills.

The ability to be open and sincerely accepting of people’s unique and chosen lifestyles and the effects that these lifestyles have on their health.

The awareness and acceptance that a constant balance must be maintained between clinical and administrative demands.

A sense of humor and practical wisdom.

Time-management skills to be able to prioritize and manage diverse and sometimes equally important tasks and responsibilities.

Working Conditions:

Works occasionally in a normal office environment where there is little discomfort due to noise, heat, dust, etc.

Some exposure to lifting and pulling of patients is expected. Must regularly lift and/or move up to 10 pounds, frequently lift and move up to 20 pounds, and occasionally life and/or move up to 40 pounds.

Requires ability to interact with all staff members and participate in some community activities.

Requires extensive travel within Horry, Georgetown and Marion Counties in personal automobile, therefore, must have current drivers license, auto liability insurance and ability to operate vehicle.

Visits are made in patient’s homes which are not usually accessible to those who are unable to walk and/or climb stairs, uses appropriate equipment to stabilize walking.

Contact with patient/families with a risk of exposure to communicable diseases; may be exposed to blood body tissues and fluids regularly, as well as other hazardous waste materials.

Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and the ability to adjust focus.

While performing the duties of this job, the employee is regularly required to sit; use hands to finger, feel objects, tools and controls; reach with hands and arms; and talk and hear. The employee is required to stand, walk, stoop, kneel, crouch, and/or crawl.

Benefits & Compensation:

• Competitive salary commensurate with experience.
• Full benefits package including, healthcare, dental, vision and life insurance.
• 403(b) tax – deferred annuity plan
• Mileage Reimbursement
• Vacation & Holiday ETO Pay
• Company Cell phone
• Education reimbursement
• Family friendly / flexible work hours

Send Resume & salary requirements, including references to:

Mercy Care
Attn: Human Resources
PO Box 50640
Myrtle Beach, SC 29579