Hospice of the East Bay (HEB) is a community based program of home care for terminally ill patients. Care is given to patients and families by an interdisciplinary group. Bereavement care is provided to the family for one year after the death. Hospice services are given regardless of ability to pay, making the agency dependent on donations and insurance billing to meet operating expenses.
Reporting to the Team Manager, the Hospice Registered Nurse Case Manager is responsible for identifying the patient’s and family’s physical, psychosocial, environmental, safety and developmental needs and individualizing the patient’s plan of care based on the needs identified. The Hospice RN Case Manager coordinates patient/family care and ensures continuous assessment of each patient and family’s needs and implementation of the interdisciplinary plan of care under the direction of the attending physician and Medical Director/Hospice physician in conjunction with the interdisciplinary team.
Hospice nursing services are based on the initial and ongoing comprehensive assessment of the patient's needs and are provided in accordance with the interdisciplinary team's care plan. Each Case Manager triages and coordinates the care of up to 15 patients with the assistance from Revisit Nurses and in collaboration with the Team Manager.
Identify and address signs of actively dying
Communicating and collaborating with patient care, MSW and SCC
Hospice nursing services include:
Assessing all aspects of the patient’s pain and developing an individualized pain management plan.
Anticipating, preventing and treating undesirable symptoms or secondary symptoms
Identifying and addressing comfort care needs.
Supporting, instructing and educating the patient, family and caregiver using teach back.
Documenting problems, nursing assessments, appropriate goals, care provided, care interventions and patient and family outcomes achieved from intervention and care provided.
Maintaining the dignity, confidentiality and privacy of the dying patient.
Supporting the patient’s unique spiritual and cultural beliefs.
Providing holistic, family-centered care across treatment settings to improve the quality of life.
Consulting and collaborating with the interdisciplinary team and others involved in the patient’s care.
Coordinating and managing patient care with awareness of insurance benefits, necessary authorizations and cost containment.
Coordinating patient care plan with After Hours and Crisis Care Staff.
Attend, document and present appropriate patient-related information at the Interdisciplinary Team Meetings utilizing the IDT templates.
Updating the comprehensive assessment and patient’s progress towards desired outcomes at least every 15 days.
Supporting the patient’s unique spiritual and cultural beliefs.
Completing patient-related documentation within 2 hours of the shift worked.
Adhering to and complies with state and federal regulations, as well as accreditation standards.
Providing patient and primary caregiver education/training, as appropriate, for care and services identified in the plan of care.
Adhering to evidence based standards of practice that are endorsed by the agency.
Identify and address signs of transitioning
Coordinate care for transfers to GIP level of care
Coordinate care for transfers to respite level of care
Coordinate care with Ahf, RCFE, & SNF
Educate and document education of caregivers (home and facility) utilizing appropriate educational tools.
Other Case Management responsibilities:
Communicating with Team Manager as appropriate regarding patient acuity, scheduling, workload, and difficult situations.
Completing necessary records, reports and documentation in a timely manner according to agency requirements.
Following the agency’s process for effective hand off communication.
Participating in educating new staff members as assigned by the Team Manager.
Supervising performance of Home Health Aide.
Supervising performance of LVN.
Attending appropriate in-services held for Hospice of the East Bay staff.
Participating, as requested, in QAPI activities.
Initiating and ongoing monitoring of medication reconciliation processes according to Medicare and accreditation standards.
Respond to email and voice mail communication in a timely manner.
Must have the ability to perform a complete nursing physical assessment, develop a comprehensive care plan and respond to the needs of patients and families in the home setting, which include SNF, RCFE/Board & Care. Must be able to cope with patient/family emotional stress and be tolerant of individual lifestyles without judgment. Must have ability to establish professional boundaries and maintain cooperative relationships with professionals. Must demonstrate excellent interpersonal communication skills, customer service skills, initiative, dependability and good judgment. Must be able to work collaboratively as part of an interdisciplinary team, as well as independently, and problem solve in a crisis situation. Must take (and pass with 85% or more) a medication calculation competency exam annually.
Experience & Education
Current California Registered Nurse License required.
A minimum of one year of experience working as a professional nurse in an acute clinical setting required.
CPR certification required.
Must have current California Driver’s License and a car in good working condition.
Prior experience in hospice and/or home care preferred.
Hospice and Palliative Care Nurse Certification highly desirable.
Hospice is a specialized, personalized approach to medical care and support at the end of life. Care is focused on honoring patients' wishes, ensuring their personal dignity, and providing physical, emotional, and spiritual comfort.Since 1977, Hospice of the East Bay has been effective in improving the quality of life for patients with life-limiting illnesses by providing expert, compassionate car...e in the comfort and privacy of home. "Home" may be a patient's residence, that of a friend or relative, or an assisted living, residential care, or skilled nursing facility--or our Bruns House inpatient hospice facility. The goal of care is to make our patients as comfortable and pain free as possible and to ease their sense of loneliness and fear.At our hospice, all medically qualified patients receive services, without regard to race, religion, age, gender, sexual orientation, disability (mental or physical), place of national origin, insurance status or ability to pay. Family members of our patients are trained to confidently care for their loved one, with the constant support of their hospice team. They also are assisted as they cope with their own emotional, spiritual, and practical needs.Hospice team members are available 24-hours a day, 365 days a year. It is our mission to be by the sides of our patients and their families, every step of the way, so that they do not feel alone and are ensured the best possible quality of life during the important final phase of life.