Responsible to the Director of Professional Services, Patient Care Coordinator to provide nursing care and case management to Patients and families. Implements nursing interventions and coordinates the Patient/family interdisciplinary plan of care. Supervises personnel to deliver care and coordinates care delivery.
Essential Job Functions
Every effort has been made to make your job description as complete as possible. However, it in no way states or implies that these are the only duties you will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar or is a logical assignment of the position.
• Manages a Patient and family caseload which includes assessing, planning, implementation, evaluating and documenting the care provided.
• Plans, coordinates and delivers nursing care to Patients and families.
• Supervises and documents home health aide/licensed practical nurse plans of care and documents supervisory visits.
• Participates in on-call coverage.
• Submits paperwork in a timely manner and updates and maintains Patient medical records.
• Participates in regularly scheduled interdisciplinary team meetings to coordinate the care of the Patient and family, exchange information and problem solve, and receive staff support and education.
• Applies the policies and procedures of the agency and the rules and regulations of Federal and State regulatory agencies and other certifying agencies in providing care.
• Coordinates and develops Patient/family plan of care and ensures the care plan is current, up to date and reviewed at every team meeting.
• Assesses & evaluates Patients level of care, needs and requirements.
• Participates in agency quality assessment performance improvement (QAPI) programs.
• Ensure growth & profitability of the company through the responsible use of company resources and educating the community to our services.
• Assesses the Patient’s response to the Plan of Care and recommends changes as needed.
• Meets or exceeds established productivity standards.
• Provides education to the Patient/family regarding the disease process, self care techniques, prevention strategies, rehab nursing procedures and community resources for discharge planning
• Initial and ongoing comprehensive assessment of patient’s needs including Outcome and Assessment Set (OASIS) at appropriate time sets.
• Evaluating Outcomes of Care.
• Provide counseling to Patient/family regarding disease process, end of life and ethical issues.
• Willingly accepts direction from Director of Professional Services/PCC.
• Participates in community programs and committees, as requested.
• Supervises LPN/LVNs, home health aides and paraprofessionals providing services to the patient according to regulatory guidelines.
General Responsibilities (Hospice Only)
• Attends deaths of Patients to assist and support the family.
• Initial and ongoing assessment of the impact of the terminal diagnosis on the Patient’s physical, functional, psychosocial and environmental needs and activities of daily living including risk for pathological grief, cultural and spiritual implications and verbal and non-verbal communication patterns.
• Implements the individualized plan of care and recommends revisions to the plan as necessary including managing discomfort and providing symptom relief and specialized nursing skills related to palliative and end-oflife care.
• 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.
• Initiates appropriate preventive and rehabilitative nursing procedures.
• Prepares clinical and progress notes that demonstrate progress toward established goals.
• Coordinates all Patient/family services and prioritization of needs with the 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 Patient’s needs and outcomes of intervention.
• Determines scope and frequency of services needed based on acuity and Patient/family needs.
• Supervises LPNs/LVNs and paraprofessionals providing services 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 insure adequate care.
• Assesses the ability of the caregiver to meet the Patient’s immediate needs upon admission and throughout care.
• Evaluates family/Patient response to care on an ongoing basis.
• Evaluates own needs for support and uses identified systems to meet the need.
• Applies specific criteria for admission and re-certification to hospice care to establish appropriate levels of care and the Patient’s eligibility.
• Communicates information using current process and technology available to the organization.
• Ensures that care is provided with respect for patient rights.
• Ensures protected health information is kept confidential
• Reports complaints made by patients or families to the appropriate persons Adheres to established personnel policies.
• Reports allegations of patient abuse, neglect and/or misappropriation of patient property.
Safety and Sanitation
• Follows standard precautions and infection control procedures.
• Reports all accidents and incidents observed.
• Identifies and responds appropriately to emergency situations.
• Assures safety needs of the patients are addressed and met.
Delivery of Care Responsibilities
• Participates in in-service training as requested by the office
• Reviews and evaluates medical treatment plans for all Patients served
• Communicates appropriate clinical information to the interdisciplinary team regarding Patient/family needs.
• Provides documentation of Patient visits on the clinical record
• In conjunction with the physician develops and orders treatment appropriate with the Patient’s disease progression and document appropriately
• Addresses Patient care needs with families and significant others as appropriate
• Collaborates with all service providers furnishing contract services to the Patient
• Participates in developing and updating policies and procedures as requested
• Maintains confidentiality of necessary information
• Thinks and acts calmly and logically to meet unusual occurrences of the job Maintains proper documentation for billing Manages time efficiently and effectively.
• Interfaces with Patients, families and staff to ensure customer satisfaction
• Develops a comprehensive discharge plan based on the interdisciplinary team assessment In conjunction with the physician, evaluates need for appropriate diagnostic studies and/or tests.
• Communicates effectively with Patients, families and other health care providers
• Maintains clinical competency by assuming responsibility for acquiring knowledge and experience to meet learning needs
Currently licensed as a Registered Nurse (RN) in the state and in good standing with the Board in which he/she will practice.
• Ability to manage Patient care with specific knowledge and experience in bedside nursing, symptom management, crisis intervention and family intervention.
• Ability to work well with an interdisciplinary team.
• Excellent written and verbal communication skills.
• Demonstrate problem solving and decision making abilities.
• Ability to develop and maintain rapport with the Patient and family.
• A minimum of 6 months institutional nursing experience within the past 3 years, unless state regulations differ. The Director of Professional Services or Administrator may waive this experience requirement based upon a personal interview.
• Registered Nurses providing skilled intervention for PASSPORT Patients must have 2 years experience as an RN.