Case Managers

Openings Mishawaka, Elkhart, LaPorte. Plymouth Patient Care: • Performs an initial and ongoing comprehensive assessment of the patient's and family's physical, psychosocial, environmental, safety and spiritual needs within 5 days of the election of hospice services, with reassessments no less frequently than every 15 days. • Develops an individualized plan of care based on a comprehensive assessment in conjunction with the patient's and family's goals. • Assesses all aspects of the patient's pain and comfort, developing and implementing an individualized pain management plan. • Provides holistic, patient/family-centered care as prescribed, in the patient's residence to improve the quality of life. • Consults and collaborates with the interdisciplinary team and other agencies involved in the patient's care. • Supports the patient, family, and caregiver in medical decision making and unique spiritual and cultural beliefs. • Provides supervision of LPN and Home Health/Hospice Aides in accordance with Agency policy and regulatory requirements. • Performs admissions as assigned. • Completes an average of 25 visits per week • Communicates appropriate information and participates at IDG meeting. Documentation: • Documents problems, nursing assessments, appropriate goals, care provided, care interventions, patient/family teaching, and patient and family outcomes. • Completes patient assessment documentation on the day care is given. • Documents all physician orders, IDG notes, and patient notes on the day work is performed. • Documents LPN, Home Health, and Hospice Aide supervisory visits every 14 days. • Helps to provide continuity of care between team members and other service providers by ensuring verbal and written reports are clear, concise, and timely. Teaching: • Teaches patient self-care. • Teaches those parts of patient care appropriate for each family, or ECF staff to provide. • Teaches indications, side effects, and contraindications of all medications. • Assists the patient’s family, or ECF staff, with understanding the illness, the dying process, plan of care, and needs of the patient. • Teaches the patient and family their rights regarding hospice care and benefits. • Serves as preceptor to other staff nurses, Aides, and students.