POSITION SUMMARY:

The RN Case Manager is a core member of the intensive in-home case management services offered by the Home Health program. Under the direction of the Clinical Nurse Manager, the RN Case Manager works collaboratively with a Social Work Case Manager partner providing the medical case management focus to a caseload of up to 45 clients in order to maintain quality healthcare across the service continuum, decrease fragmentation of care, assist the client to remain engaged in HIV care and treatment, maximize health outcomes, and remain independent in their home or community-based setting.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

  • Receive inquiries regarding participation in the Home Health Program; explain conditions of participation and obtain informed consent from clients to participate in the Home Health Program.
  • Collaborate with the Social Work Case Manager to assess whether the client is eligible for either Home-Based Case Management Program or Medi-Cal Waiver program via intake interviews including obtaining historical and current medical information. Consult with the Social Work Case Manager in setting the client’s Cognitive Functional Assessment score. Ensure that clients enrolled onto the Medi-Cal Waiver program meet the criteria for Nursing Facility Level of Care as defined by the State California Department of Public Health, Office of AIDS.
  • Perform initial comprehensive nursing assessment and ongoing reassessments, including client’s current symptoms, risk factors, and an assessment of the client’s level of care for Medi-Cal.
  • Develop the initial service plan and document the result of the intake in the prescribed format. Work collaboratively with the Social Work Case Manager assigned to the team for team case management. Work with the Social Work Case Manager to solidify the overall service plan for the client. Ensure that clients have input into the plan of care and that the client’s primary care provider is notified of the care plan and start of care.
  • Document results of the intake, subsequent contacts, reassessments, and all work performed on behalf of the client using our Client Tracking database system (C-Trac).
  • Consult with the client’s attending physician, primary care practitioner and/or other medical providers as needed to coordinate treatment plan and advocate for the client as necessary.
  • Identify services available to the client and coordinate services and/or make appropriate referrals as required in the service plan. Document services needed but not available at APLA and refer to other community based organizations.
  • Monitor the service plan regularly, at least every 90 days with the Social Work Case Manager. Ensure that services are provided based on documented need as evidenced in the assessment and reassessments.
  • Coordinate and monitor the service plan, including service providers’ performance. Negotiate with service providers when those services have either not been provided, or have been inadequately provided. Discuss with Program Manager before approaching contracted workers with feedback.
  • Maintain timely and appropriate contact (as specified in the Joint AIDS Case Management Protocols/County Contracts) with assigned clients. Clients are to be seen minimally every 90 days for face-to-face reassessment, and have contact beyond that as indicated.
  • Identify and follow up on instances of abuse, neglect, and exploitation that bring harm or create the potential for harm to clients.
  • Establish working relationships with members of the client’s social support systems (e.g. significant others, family members, friends, conservators, etc.). Provide emotional and practical assistance to help them in maintaining their support to the client.
  • Adhere to all applicable professional, legal, and ethical standards of clinical practice in the provision of services, including but not limited to: mandated reporting, provision of effective services, case documentation, client confidentiality/HIPAA regulations, ensuring client safety, and maintaining professional boundaries.
  • Attend case conferences and interdisciplinary treatment team meetings, present reports and collaborate with other team members, document the outcome of the team decisions in the client’s chart.
  • Obtain training annually on topics including HIV/AIDS, medical case management strategies, psychosocial needs, and co-morbid disorders.
  • Document all actions made on a case in the specific client record in accordance with protocols.
  • Accurately complete all documents in a timely manner.
  • Attend unit, division, and other agency meetings as assigned.