GBMC HealthCare

Manager

• Completes initial assessment of patient and family to ascertain home care needs - including physical, emotional, spiritual and mental status.
• Prepares and implements the care plan for patient/family unit in collaboration with the Interdisciplinary Group.
• Provides direct nursing care to patients in order to maintain highest level of care for the patient in conjunction with the primary physician.
• Plans and supervises the delivery of care by the HHA
• Cooperates with Clinical Manager in utilization of other team members, outside agencies, and community resources. Updates primary physician when necessary and regularly on a monthly basis. Updates interdisciplinary team at patient care conference
• Uses problem oriented charting to ensure continuity of care in a home setting or nursing home as well as inpatient or respite setting.
• Teaches family members, facility staff , hired caregivers, patient care skills, including: pain control, medication (RN titrates medication within prescribed range), injections, draws blood for labs, manages IV's, dressing changes, hygiene, nutrition, checking vital signs in accordance with orders from physician, as well as addressing emotional needs.
• Ensures that arrangements for equipment necessary in the facility setting are made available.
• Attends to patient, family and facility at time of patient’s death.
• Documents in facility chart
• Maintains positive relationships and open communication with facility staff.
• Reconciles medications against facility medication list.
• Updates facility staff and family of visit schedule
• Attends care plan meetings and/or patient care rounds for hospice patients within the facility.
• Establish/maintain professional working relationships with a variety of facility staff; ED, DON, medicine techs, aides, nurses (LPNs and RNs), rehab staff, housekeeping, etc.
• Provide educational in-services to facility staff both formally and informally.
• Participate in marketing and customer service activities with BDMs.

Hospice RN Case Manager

Medical writer

• Under limited supervision from the Director of Primary Care and Senior Director of Population Health, the Clinical Documentation Improvement (CDI) Nurse will assist GBMC Health Partners physicians and advanced practicing clinicians to accurately document patient clinical acuity and illness burden to improve risk management efforts.
• The CDI Nurse will review patient records, including ICD-10 diagnoses and Hierarchical Condition Categories (HCC) to identify and act on opportunities for improvement.
• This resource will also educate and work with providers, system leaders, and EPIC staff to maximize documentation accuracy and efficiency.

Clinical Documentation Improvement Nurse

Community Manager

• Completes initial assessment of patient and family to ascertain home care needs including physical, emotional, spiritual and mental status.
• Prepares and implements the care plan for patient/family unit in collaboration with the Interdisciplinary Group.
• Provides direct nursing care to patients in order to maintain highest level of care for the patient in conjunction with the primary physician.
• Plans and supervises the delivery of care by the HHA.
• Updates primary physician when necessary and regularly on a monthly basis.
• Updates interdisciplinary team at patient care conference.
• Uses problem oriented charting to ensure continuity of care in a home setting or nursing home as well as inpatient or respite setting.
• Teaches family members, facility staff, hired caregivers, patient care skills such as: pain control, medication, injections, draws blood for labs, manages IV's, dressing changes, hygiene, nutrition, checking vital signs in accordance with orders from physician, and addressing emotional needs.
• Ensures that arrangements for equipment necessary in the facility setting are made available.
• Attends to patient, family and facility at time of patient’s death.
• Documents in facility chart.
• Maintains positive relationships and open communication with facility staff.
• Reconciles medications against facility medication list.
• Updates facility staff and family of visit schedule.
• Attends care plan meetings and/or patient care rounds for hospice patients within the facility.
• Establishes and maintains professional working relationships with a variety of facility staff; ED, DON, medicine techs, aides, nurses (LPNs and RNs), rehab staff, housekeeping, etc.
• Provides educational in-services to facility staff both formally and informally.
• Participates in marketing and customer service activities with BDMs.

Senior RN Case Manager – Senior Living Community

• Completes initial assessment of patient and family to ascertain home care needs - including physical, emotional, spiritual and mental status.
• Prepares and implements the care plan for patient/family unit in collaboration with the Interdisciplinary Group.
• Provides direct nursing care to patients in order to maintain highest level of care for the patient in conjunction with the primary physician.
• Plans and supervises the delivery of care by the HHA.
• Cooperates with Clinical Manager in utilization of other team members, outside agencies, and community resources. Updates primary physician when necessary and regularly on a monthly basis. Updates interdisciplinary team at patient care conference.
• Uses problem oriented charting to ensure continuity of care in a home setting or nursing home as well as inpatient or respite setting.
• Teaches family members, facility staff, hired caregivers, patient care skills, including: pain control, medication (RN titrates medication within prescribed range), injections, draws blood for labs, manages IV's, dressing changes, hygiene, nutrition, checking vital signs in accordance with orders from physician, as well as addressing emotional needs.
• Ensures that arrangements for equipment necessary in the facility setting are made available.
• Attends to patient, family and facility at time of patient’s death.
• Documents in facility chart.
• Maintains positive relationships and open communication with facility staff.
• Reconciles medications against facility medication list.
• Updates facility staff and family of visit schedule.
• Attends care plan meetings and/or patient care rounds for hospice patients within the facility.
• Establish/maintain professional working relationships with a variety of facility staff; ED, DON, medicine techs, aides, nurses (LPNs and RNs), rehab staff, housekeeping, etc.
• Provide educational in-services to facility staff both formally and informally.
• Participate in marketing and customer service activities with BDMs.