It is the responsibility of the Nurse Case Manager to coordinate and provide the highest level of hospice care to patients and families. The Nurse Case Manager works in conjunction with the Director of Patient Care Services and the Interdisciplinary Group to:
• Assume overall responsibility for organizing patient care from an Interdisciplinary Group approach.
• Provide hands-on clinical nursing, interacting with patients, family, physicians, Interdisciplinary Group members, and other health care professionals involved in the patient’s care.
• Assess and implement a pain/symptom management program formulated with the participation of family and patient, attending physician and the Interdisciplinary Group, utilizing pharmacological and non-pharmacological methods of pain/symptom control to enhance quality of life.
• Assist in facilitating freedom of choice, relief of suffering and death with dignity for patients facing end of life issues.
• Provide support and education for families based on the hospice philosophy of care. Care includes physical, psychological, spiritual and financial comfort.
• Participate in Interdisciplinary Group meetings and up-date the Plan of Care for assigned patients based on identified problems and needs.
• Ensure all services provided are in accordance with the patient’s Plan of Care.
• Ensure the POC involves the active participation of the patient, family, PCP and the Interdisciplinary Group.
• Coordinate all services related to hospice care for assigned patients. Coordination of services include communicating and making referrals for home health aide/homemaker, spiritual counselor, social work, volunteer and ancillary services, as well as, ordering medications and Durable Medical Equipment, patient transfers to GIP, Respite, and LTP.
• Educate patient and family on the disease, disease process and expectations related to the disease.
The Nurse Case Manager will be on call according to prepared schedule. During the hours when on all, the Nurse Case Manager is expected to follow the On Call Protocol and to respond to all pages within 20 minutes.