MDS assessments following RAI guidance; Data collection and entry; Program manager responsibilities; 1:1 meetings with residents; Lead treatment plan reviews; Physical health checks/assessments; Mental health assessments; Provide education on mental health management; Mood interviews; DISCUS/AIMS and MOSES assessments; Medication management and training; Coordination with interdisciplinary team including floor nurses, DON, MSW, dietitian and physicians; Running monthly weight variances; Functional assessments; Significant change of condition assessments; Initiating and revising care plans.
RN Case Management; Managing therapy teams with weekly collaboration; Working closely with Doctors to provide the best care; Wound care; Wound Vac; IV blood draws; Suprapubic and foley catheter changes; Education to patients and families; Voluntary participation in QAPI, STAR committee, safety committee, and WIG program; Head to toe assessments, OASIS assessment and use of POINTCARE EMR; Initiating individualized care plans and keeping them up to date; Start of care, recertification, ROC, and discharge visits; Active participation in weekly nurse meetings; Managing schedules for visit nurse and HHA; Working with different patient insurance companies to ensure coverage in home care service; Providing community resources.
RN Case Management; Managing therapy teams with weekly collaboration; Working closely with Doctors to provide the best care; Wound care; Wound Vac; IV blood draws; PICC dressing change; PICC blood draw; Suprapubic and foley catheter changes; Education to patients and families; Voluntary participation in QAPI and WIG program; Head to toe assessments, OASIS assessment and use of Netsmart; Initiating individualized care plans and keeping them up to date; Start of care, recertification, ROC, and discharge visits; Active participation in weekly nurse meetings; Managing schedules for visit nurse and HHA; Working with different patient insurance companies to ensure coverage in home care service.