RN Case Manager- Home Health
Berkshire HealthcareEast Longmeadow, MA
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Job Description
- Assesses patients' physical, and psychosocial needs in a sensitive caring manner following established Standards of Nursing Practice and Home Health procedures.
- Assesses patient/family learning needs, style and limitations and adjusts for delivery of information
- Establishes realistic goals and develops individualized plans of care in collaboration with the patient, family and members of the health care team
- Collaborates with patient/family and other healthcare providers and/or community resources with planning of care and discharge.
- Follows physician orders on all patients assigned in accordance with patient care policies
- Reconciles medications with patient and physician consistently
- Effectively manages assigned case load, within the team model of care delivery
- Establishes a daily work plan based upon patient/family priorities of service and total area needs.
- Promptly triages patient visits, messages, and phone calls according to priority and urgency.
- Demonstrates excellent physical assessment and care planning skills.
- Supervises HHA in accordance with state and federal requirements.
- Demonstrates knowledge of pharmacology and medication administration and reconciliation
- Communicates and collaborates with all disciplines in the home care setting on a regular basis or immediately if there are any critical needs or crisis interventions.
- Completes documentation accurately and timely
- Performs on-call responsibilities and on call services to patients and families assigned
- Participates in agency quality management and safety activities
- Participates in ongoing staff meetings and in-services
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