Conducts medical home visits on established Care Coach Connect patients performing a hands on exam at each visit Conducts urgent/acute visits on established Care Coach Connect patients with the goal of keeping the patient out of the hospital in order to receive the best medical care at home Provides ongoing assessments of the impact of life-limiting and/or chronic illness(es) on the patients physical, functional, psychosocial and environmental needs Assess for caregiver burnout, and provide comm... more details
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The Care Coach Connect RN/Case Manager coordinates care and provides initial ongoing nursing assessment of the patient and family needs and coordination of the patients plan of care with interdisciplinary team members and the Care Coach Connect supervising clinician.
Primary Responsibilities:
- Conducts medical home visits on established Care Coach Connect patients performing a hands on exam at each visit
- Conducts urgent/acute visits on established Care Coach Connect patients with the goal of keeping the patient out of the hospital in order to receive the best medical care at home
- Provides ongoing assessments of the impact of life-limiting and/or chronic illness(es) on the patients physical, functional, psychosocial and environmental needs
- Assess for caregiver burnout, and provide community resources when appropriate
- Implement the individualized plan of care and recommend revisions to the plan as necessary
- Ability to perform procedures, to include, but not limited to:
- Wound care and dressing changes
- Phlebotomy
- Injection (B12, vaccines)
- Ability to conduct an advanced care discussion with a patient and their family and properly document their wishes in the electronic medical record
- Consults and educates the patient/family and other caregivers regarding the disease process, pain and symptom management, end of life care and processes for dealing with issues of ethical concern
- Initiates appropriate preventive and rehabilitative nursing procedures when appropriate
- Ensure continual assessment of patient and family needs from admission to Care Coach Connect throughout the course of care
- Provides ongoing evaluation of the patient and family/caregiver response to care, and recommends alteration of the plan when necessary
- Attends the interdisciplinary meeting and is a crucial and vocal member of the team
- Solves problems by gathering and/or reviewing facts and selecting the best solution from identified alternatives. Decision making is usually based on prior practice or policy, with some interpretation. Applies individual reasoning to the solution of a problem devising or modifying processes andwriting procedures
- Conducts telephonic nursing follow up and case management when necessary
- Serves as a resource or consultant for LVN
- Attends educational offerings to keep abreast of chronic medical conditions and complies with licensing requirements
- Establishes a trusting relationship with identified patients, caregivers, clinic staff members and Providers
- Collaborates with the providers to recommend policies, procedures and standards which affect the care of the Care Coach Connect Patient
- Exhibits professionalism and is courteous with all patients, physicians and co-workers
- Informs the provider of patients needs and outcomes of interventions as per standards
- Follows Care Coach Connect providers orders regarding the scope and frequency of services needed based on acuity and patient/family needs
- Coordinates all patient/family services and prioritization of needs with the members of the interdisciplinary team
- Documents in the electronic health record progress toward established goals as per standards
- Uses the case management approach and refers to other services as needed
- Maintains a patient case load, daily visits and point of care documentation levels as per standards
- Performs all other related nursing duties as assigned
Youll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
Required Qualifications:
- Registered Nurse with a current license to practice in the state of employment
- 3+ years of experience in a physicians office, clinical, hospice or hospital setting
- Current BLS certification or must obtain certification within 30 days of employment hire date
- Able to travel 75 to 100% of the time
- Must have reliable transportation for daily travel to various locations as assigned
- Valid drivers license within the state of work
- Excellent verbal and written skills
- Ability to interact productively with individuals and with multidisciplinary teams
- Demonstrated knowledge of Word, Excel, Outlook and EMR systems
- Proven excellent organizational and prioritization skills
Preferred Qualifications:
- Experience with home visits
- Knowledge of palliative and hospice medicine
- Bilingual in Spanish or Vietnamese
- Experience related to advanced care planning and discussions with patients regarding end-of-life wishes
- 2+ years of hospice experience
- Hospice or Palliative Care Nursing certification
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