Company Information

At Community Hospice & Health Services and its affiliates, Community Hospice & Health Services Foundation, and CHI Management, Inc. (herein referred to collectively as “CHHS”) you will find a family-based and compassionate work environment. Our goal is to provide a wonderful work experience that allows our employees to thrive by feeling engaged and fulfilled each day. CHHS is the largest and oldest nonprofit hospice, palliative care, and support services provider in the Central Valley.

We are proud to indicate that CHHS has been supporting and providing compassionate and quality services to our community since 1979. Our mission is to embrace individuals and families facing life-changing journeys, enhancing quality of life for all. CHHS is accredited by Community Health Accredited Program (CHAP).

Department: Patient Care Services

REPORTS TO: Patient Care Manager

SUMMARY:  As a member of the interdisciplinary team (IDT), the RN Case Manager (RNCM) works under the general direction of the Patient Care Manager (PCM).   The RNCM provides skilled nursing assessment, care planning, and interventions in accordance with the plan of care and Community Hospice’s policies and procedures in order to maximize the comfort and quality of life for patients /families /caregivers.  Location of care varies and occurs where-ever the patient calls home.

The RNCM coordinates communication between members of the IDT, including patient/family/ caregivers and attending physician.   

RESPONSIBILITIES:

• Admissions of new patients, which includes assessment, planning, implementation, and evaluation phases of the nursing process, evaluation of patient appropriateness for services, and consultations to explain services, as requested by the PCM. 
• Perform scheduled patient visits to assess needs; teach pain management, symptom control and patient care skills. Provide physical, emotional and spiritual support to the patient/family/caregiver.
• Maintain regular communication with the IDT regarding patient status including any unusual or problematic patient/family/caregiver issues
• The RNCM initiates communication with attending physicians, IDT members and other community agencies as needed to coordinate the plan of care and use of resources for patient/family/caregiver.
• Maintain up-to-date patient records so that problems, goals, and interventions are accurately and clearly documented. Changes in the plan of care are reflected as they occur. Target dates for goals in the Care Plan will be current and reflect the current recertification period when submitted for recertifications. Documentation should reflect movement of the patient toward the terminal primary diagnosis (hospice patients).
• Attend regularly scheduled IDT Meetings to review patient/family/caregiver needs, problem solve and cover unique patient issues. Share professional support, resources and exchange feedback aimed toward enhancing professional growth.
• Accept responsibility for coordinating care of the patient for IDT members, teaching primary caregivers and employed caregivers, teaching facility staff, or by providing direct care as appropriate.
• Assure continuity of care for patient in all settings.
• Share in providing 24-hour, 7-days a week and holiday coverage to patient/families. Accepts assigned work duties based on patient and organizational needs as assigned by PCM and/ or Administrator on Call. 
• Attend death events (hospice patients) and provides appropriate support at time of death.
• Participate in Community Hospice education of students and community healthcare professionals and participate in the orientation of new employees.
• Participates in agency Quality Improvement process to improve level of services provided to Community Hospice patients and families and compliance to CMS Medicare regulations.
• Participate in inservices, workshops, and clinical meetings to promote professional growth and understanding of patient/family/caregiver care
• Follow all Community Hospice policies and procedures including, but not limited to, safety, infection control, privacy and confidentiality, and HIPAA. Displays a strong work ethic by accurately recording hours worked, accurate mileage reporting, and avoids unnecessary overtime. All overtime is approved by PCM.
• Must maintain RN license in accor