The RN Case Manager:

• Develops a care plan in collaboration with the patient's physician, the patient, and their family, or the primary caregivers upon admission. Periodically reviews the patient care plan and recertifies the patient care plan as appropriate.
• Coordinate the patient's care plan through interdisciplinary communication and case conferences, as appropriate. Advise other disciplines of discharges in a timely manner.
• Provide ongoing assessment of the patient's clinical, functional, and emotional status to identify problems and/or progress toward desired goals. Communicate significant changes to the patient's physician and VNA colleagues.
• Completes and submits accurate and relevant clinical notes and other required documentation in a timely manner in accordance with expected agency standards, i.e., admission papers, clinical notes, status change, verbal orders/memos; payer source documentation, including authorizations, discharge.
• Identifies and communicates concerns regarding patient safety and/or environmental safety issues to the management staff. Follows the agency policy when necessary mandatory reporting is required.
• Accepts responsibility of assignment to perform a specialized procedure and/or see patients in other programs as needed such as, but not limited to, Infusion Therapy and Hospice, precepting of students and new staff, etc.
• Document evaluations, treatment goals, and objectives.
• Teach the patient and caregiver self-care techniques as appropriate. Provide medication, diet, and other instructions as ordered by the physician and utilizes opportunities for health counseling with patients and caregivers.