Careers

The RN Case Manager is the member of the interdisciplinary team who is the pivotal person in identifying the physical, psychological, social and spiritual needs of the patient and family. RN Case Manager initiates appropriate intervention and support for the patient and family upon admission and provides a continuously appropriate, comprehensive and responsive plan of care.

Essential Job Functions/Responsibilities:

Case Management and Supervision
• Coordinates the patient’s and families care and services including those of the team, social worker, licensed vocational nurse, home health aide and physician.
• Responds necessary information to the senior case manager.
• Monitors the re-certification / re-authorization process.
• Participates in Interdisciplinary Team Meetings as indicated.
• Ensures and documents appropriate use of the medications, durable medical equipment and supplies.
• Educates patients, families and other caregivers.
• Provides skilled nursing as determined by the interdisciplinary plan of care.
• Appropriately utilizes the skills and resources of contract personnel such as PT, OT, Dietary, Speech and Pharmacy.
• Provides appropriate care plan and integrates care plans as needed.
• Performs on site evaluations of Certified Home Health Aides (CHHA).
• Participates in the on-call rotation and weekends.

Quality Improvement
• Integrates QI results into the established plan of care.
• Participates in QI assessment routinely.
• Participates in proactive patient calls.
• Participates in routine chart reviews.

Professional Development
• Participates in the orientation of new team members as assigned by the Team Manager.
• Attends regularly scheduled in-services and educational conferences.
• Develops and achieves professional growth goals and objectives and reviews with the Team Manager.
• Represents professional nursing.

Preferred Skills
• Excellent observation, diagnostic, medication management and clinical documentation skills

Professional Requirements and Required Certification/Licensure
• Current/valid Registered Nurse license in the State of California.
• Two to three years of hospice or home health nursing experience.
• Knowledge of State and Federal regulations relating to hospice or home health participation.

The Registered Nurse plans, organizes and directs patient care and is experienced in nursing, with emphasis on community health education/ experience. The professional nurse builds from the resources of the community to plan and direct services to meet the needs of individual and families within their homes and communities.

Essential Job Functions/Responsibilities

Patient Care
• Completes an initial, comprehensive and ongoing comprehensive assessment of patient and family to determine patient needs. Provides a complete physical assessment and history of current and previous illness(es).
• Provides professional nursing care by utilizing all elements of nursing process.
• Assesses and evaluates patient’s status by: Writing and initiating plan of care, Regularly re-evaluating patient and family/caregiver needs, and Participating in revising the plan of care as necessary
• Initiates the plan of care and makes necessary revisions as patient status and needs change.
• Uses health assessment data to determine nursing diagnosis.
• Develops a care plan that establishes goals, based on nursing diagnosis and incorporates palliative nursing actions. Includes the patient and the family in the planning process.
• Initiates appropriate preventive and rehabilitative nursing procedures. Administers medications and treatments as prescribed by the physician in the physician’s plan of care.
• Counsels the patient and family in meeting nursing and related needs.
• Provides health care instructions to the patient as appropriate per assessment and plan.
• Assists the patient with the activities of daily living and facilitates the patient’s efforts toward self-sufficiency and optional comfort care.
• Acts as Case Manager when assigned by Clinical Supervisor and assumes responsibility to coordinate patient care for assigned caseload.
Communication
• Completes, maintains and submits accurate and relevant clinical notes regarding patient’s condition and care given. Records pain/symptom management changes/outcomes as appropriate.
• Communicates with the physician regarding the patient’s needs and reports changes in the patient’s condition; obtains/receives physicians’ orders as required.
• Communicates with community health related persons to coordinate the care plan.
• Teaches the patient and family/caregiver self-care techniques as appropriate. Provides medication, diet and other instructions as ordered by the physician and recognizes and utilizes opportunities for health counseling with patients and families/caregivers. Works in concert with the interdisciplinary group.
• Provides and maintains a safe environment for the patient.
• Assists the patient and family/caregiver and other team members in providing continuity of care.
• Works in cooperation with the family/caregiver and hospice interdisciplinary group to meet the emotional needs of the patient and family/caregiver.
• Attends interdisciplinary group meetings.

Additional Duties
• Participates in on-call duties as defined by the on-call policy.
• Ensures that arrangements for equipment and other necessary items and services are available.
• Supervises ancillary personnel and delegates responsibilities when required.
• Assumes responsibility for personal growth and development and maintains and upgrades professional knowledge and practice skills through attendance and participation in continuing education and in-service classes.
• Fulfills the obligation of requested and/or accepted case assignments.
• Actively participates in quality assessment performance improvement teams and activities.

Preferred Skills
• Excellent observation, diagnostic, medication management and clinical documentation skills

Professional Requirements and Required Certification/Licensure
• Current/valid Registered Nurse license in the State of California.
• Two to three years of hospice or home health nursing experience.
• Knowledge of State and Federal regulations relating to hospice or home health participation.

The Licensed Vocational Nurse is responsible for providing direct patient care under the supervision of a registered nurse. Responsibilities include following the plan of care, providing treatments, and working collaboratively with the members of the team to help meet positive patient care outcomes.

Essential Job Functions/Responsibilities
• Provides direct patient care as defined in State Nurse Practice Act for LVN’s.
• Implements current nursing practice following a patient assessment and an approved plan of care initiated by the registered nurse.
• Provide accurate and timely documentation of patient services to reflect the plan of care.
• Assess and provide patient and family/caregiver education and information pertinent to diagnosis and self-plan of care.
• Participates in coordination of hospice and home health services, appropriately reporting the identified needs for hospice and home health interdisciplinary group members.
• Uses equipment and supplies effectively and efficiently.
• Provides appropriate pain/symptom management. Evaluates patient’s response to treatments/medications.
• Participates in personal, professional growth and development.
• Participates in organization’s quality management program.
• Participates in the on-call rotation and weekends.
• Performs other duties as assigned by the Case Manager/ Team Manager.

Preferred Skills
• Excellent verbal and written communication, and organization skills.
• Knowledge of mobile telephone usage
• Computer skills related to MS programs

Professional Requirements and Required Certification/Licensure
• Currently, valid, non-restricted California LVN license.
• Graduate of an accredited vocational nursing program.
• Three to five years of nursing experience.
• Community health/hospice, home health or medical/surgical experience is preferred.

Certified Home Health Aide (CHHA) is trained to provide personal care and services to patient to augment that care given by family members. The CHHA functions under the direction, instruction and supervision of the Case Manager and/or the Team Manager.

Essential Job Functions/Responsibilities
• Take patient vital signs and record. Notify Case Manager or Team Leader of any/all abnormal results
• Assisting patients with bath, care of mouth, skin, hair and all aspects of personal hygiene
• Assisting patients with transferring and assisting with ambulation
• Assisting with prescribed exercises which patients and CHHA have been taught by the appropriate health personnel
• Preparing of meals and assisting patients with eating
• Assisting patients with toileting including use of bedpan, urinal and commodes.
• Preparing household services that will facilitate the patient’s self-care at home and are necessary to prevent or postpone institutionalization
• Reporting changes in the patients condition and needs to the Case Manager or Team Leader
• Completing appropriate records in a timely manner

Preferred Skills
• As per Certification requirements

Professional Requirements and Required Certification/Licensure
• Provides sufficient documentation of having passed a skills test and written/oral test demonstrating those competencies identified in OBRA-87, 42 C.F.R. Sections 484.36 and 484.4. In lieu of such documentation, a newly hired CHHA must demonstrate skills and written/oral competency prior to working independently with the patient.
• High School graduate or equivalent preferred
• Proof of California State Certification for Home Health Aide (CHHA)
• One to two years of direct patient care experience in an hospice or home health setting

The social worker is the member of the interdisciplinary team whose primary function is to provide diagnostic assessments of the psychosocial and economic needs of the patient/family unit, define social service goals for alleviating these needs and help provide both the counseling and casework needed to meet these goals.

Essential Job Functions/Responsibilities
• Participates in the preparation, evaluation and implementation of the interdisciplinary plan of care to assure that the highest quality of social services is offered to patients/families and that the goals of continuity and comprehensiveness of care are achieved.
• Provides psychosocial assessments and counseling to patients/families.
• Maintains appropriate documentation in the hospice patient chart.
• Attends Interdisciplinary Team (IDT) meetings for case review and development of plan of care.
• Participates in in-service education programs.
• Assists in developing and maintaining collaborative relationships with community medical/health care services.
• Act as a resource for other IDT members of the interdisciplinary team at the direction of the team manager.
• Performs additional tasks as assigned by DPCS.

Preferred Skills
• Knowledge of stress of repeated loss as well as to provide support to the rest of the team
• Knowledge of community resources and the ability to utilize these resources.
• Knowledge of the end of life process and bereavement.
• Capacity to relate and work as a member of an IDT.
• Knowledge of non-invasive pain and symptom control.
• Knowledge of relaxation therapy, guided imagery and visualization for selected patients.

Professional Requirements and Required Certification/Licensure
• Masters in Social Work or Licensure in clinical social work
• One to two years of experience in hospice or home health social work
• Supervisory experience desired
• Demonstrates the ability to use good listening and communication skills.