RN Case Manager - On Call (PT)

• Assume primary responsibility for the patient/family caseload that includes assessing, planning, implementing, and evaluating care needs during on-call hours in collaboration with the triage team

• Report On-Call activities to the clinical leadership and Branch RN Case Managers at the end of the call shift

• Maintain and complete appropriate care coordination notes for visit notes, and other pertinent clinical information

• Assist, provide, or arrange for delivery of medications and supplies needed after business hours, weekends, and/or holidays

• As scheduled, attend interdisciplinary team meetings during on-call period for full team discussion, consultation and evaluation of patient/family needs

• Under the physician’s order, admits patients eligible for hospice services in collaboration with the triage team

• Reports patient status and need for other disciplines to clinical leadership, attending physician and hospice physician

• Develops patient care plan that specifically addresses identified patient problems; nursing problems and goals that has been identified as mutually agreed upon goals with patient(s) during on-call hours, weekends and/or holiday(s)

• Be responsible to ensure the use of the 4Ms (What Matters to the patient, Medications, Mentation, and Mobility) and provide Age-Friendly Care