I believe that better care begins at home. Compassionate care, uncompromising service and clinical excellence thats what our patients have come to expect from our clinicians. Kindred at Home, a division of Kindred Healthcare Inc., is the nations leading provider of comprehensive home health, hospice, and non-medical home care services.
Kindred at Home, and its affiliates, delivers compassionate, high-quality care to patients and clients in their homes or places of residence, including non-medical personal assistance, skilled nursing and rehabilitation and hospice and palliative care. Our caregivers focus on each unique patient to deliver the appropriate care and emotional support to our patients and their families.
Primary function as a Case Manager Registered Nurse plus On Call Exempt Hospice is to coordinate patient care with the interdisciplinary team, physician, patient/family and referring agency, administer skilled nursing care for clients of all ages in their place of residence and assume responsibility for coordination of care. Provide after-hours oncall service by serving as first point of contact from patients and customers, and provide appropriate assessment, treatment, and/or follow-up.
Case manages and provides clinical directions to the int Review the comprehensive interdisciplinary plan of care with the IDG Team. Communicate in writing in the chart and verbally with report on the previous nights problems to coordinate interventions and ensure continuity of care.
Ensures initial assessment of the patient/family and identifies risks and interventions on admission. Develops initial Plan of Care (POC) with IDT input on admission. Coordinates the implementation of the Plan of Care (POC) with a focus on palliative care and provides nursing services in accordance with the POC.
Provides initial and on-going assessment of the impact of the terminal diagnosis on the patients physical, functional, psycho-social and environmental needs and activities of daily living. Implements the individualized Plan of Care (POC) and recommends revisions to the plan as necessary.
Facilitate the implementation of nursing interventions and appropriate preventative and therapeutic nursing procedures for problems that occur after hours, including direct patient care as necessary.
For after hours concerns, conduct initial nursing assessment, including physical and psychosocial aspects of patient/family/caregiver in a thorough, accurate, compassionate and timely fashion.
Consistently collaborate with the physician to plan and implement the medical and nursing plan of care of any after hours problems. Review the comprehensive interdisciplinary plan of care with the IDG Team. Communicate in writing in the chart and verbally with report on the previous nights problems to coordinate interventions and ensure continuity of care.
Provides care utilizing infection control measures that protect both the staff and the patient (OSHA). Assesses risk for pathological grief including cultural and spiritual implications. Provides case management and coordination of care, appropriate referral and follow-up and utilization review. Manages discomfort and provide symptom relief.
Consults with and educates the patient/family regarding the disease process, self-care techniques, end-of-life care and the processes for dealing with issues of ethical concern. Facilitates the implementation of another level of hospice care when necessary.
Initiates appropriate preventative and rehabilitative nursing procedures. Prepares clinical and progress notes that demonstrate progress toward established goal(s). Coordinates all patient/family services and prioritizes needs with members of the interdisciplinary team. Uses case management approach and refers to other services as needed.
Informs the physician and other personnel of changes in the patients needs and outcomes of intervention. Determines scope and frequency of services needed based on acuity and patient/family needs
Supervises and provides direction to Certified Hospice Aide at a minimum, every two weeks, to ensure quality and continuity of service are provided to the patient according to regulatory guidelines. Supervises and provides direction to LPNs/LVNs at a minimum, monthly, to ensure quality and continuity of service are provided to the patient according to regulatory guidelines. Participates in in-service programs. Provides specialized hospice training to other staff, family members and informal caregivers to ensure adequate care.
Provides and documents on-going evaluation of patient/family response to care. Assesses the ability of the caregiver to meet the patients immediate needs upon admission and throughout care. Evaluates own needs for support and uses identified system(s) to provide support and needs. Applies specific criteria for admission and re-certification to hospice care to establish appropriate levels of care and patients eligibility.
Participates in the hospice performance improvement program. Provides services in accordance with Kindred at Home organizational policies and procedures and regulations that define scope of practice. Provides dietary counseling and services as indicated in accordance with the Plan of Care.
Completes self evaluation skills annually and peer evaluation of skills as requested. Perform on-call responsibilities and provide on-call services to patients/families as assigned. Monitor assigned cases to ensure compliance with requirements of third party payer. Performs other related duties as assigned or requested
Graduate of an accredited Diploma, Associate or Bachelors School of Nursing
Current state license as a Registered Nurse
Current drivers license. Must have reliable transportation and insurance
Proof of current CPR certification
Two years experience as a Registered Nurse in a clinical care setting, home health or hospice preferred
Ability to work flexible schedule (including PRN emergency calls) and travel locally
