Course Code: REL-PAC-0-PCCMHC
Hours: 1
Type: Online Course
Content Expiration Date: 12/31/2028
Learning Objectives:
Recall the elements of the RN case management model of care in hospice.
Recognize the importance of case management throughout hospice, on-call services, and hospice care provided in long-term care settings.
Identify the role of RN case managers and social workers in patient outcomes and QAPI.
Outline:
Section 1: Understanding Case Management in Hospice
The Case Management Model as a Framework
RN Case Manager Role
Patient Outcomes and RN Accountability
Advantages of the RN Case Management Model
Disadvantages and System-Level Challenges
Social Work Perspective
Partnering in Case Management
Review
Key Takeaways
Section 2: Case Management Throughout the Hospice Stay
Admission and Plan of Care Development
RN: Assessment, Care Coordination, and Goals
SW: Psychosocial Assessment, Caregiver Needs, and Cultural Context
IDG Collaboration and the Plan of Care
Patient Outcome Examples
Levels of Care
Recognizing the Need for a Higher Level of Care
General Inpatient Care (GIP)
Continuous Home Care (CHC)
Coordinating Inpatient Respite Care
Case Management and IDG Coordination
Patient Outcome Examples
Coordination in the Final Days of Life
Recognizing Imminent Death and Revising the Plan of Care
Planning and Communication During Active Dying
Supporting Families and Preparing for Death
Patient Outcome Examples
Review
Key Takeaways
Section 3: Challenges in Care Coordination
Meeting 24/7 Care Needs: CMS Requirements
Coordination Responsibilities of the RN
On-Call Challenges and Remedies
Patient Outcomes
Supporting Patients in Long-Term Care Settings
Coordinating Hospice and Facility Responsibilities
The Role of the Social Worker
Patient Outcome Examples
Review
Key Takeaways
Section 4: Quality Assessment and Performance Improvement
What QAPI Is and Why It Matters
Identifying Areas for Improvement
What Does Data-Driven QAPI Look Like?
The RN Case Manager
Social Work Perspective
Review
Key Takeaways
Section 5: Conclusion
Course Summary
Course Contributor
Resources
References
Subject Matter Expert: Susan Heinzerling, BSN, RN, CHPN
Susan Heinzerling earned a Bachelor of Science in biology and a Bachelor of Science in nursing from the University of North Carolina at Chapel Hill as well as a Master of Life Sciences in physiology from North Carolina State University. She became a doctoral candidate in immunology at the University of South Alabama. Her research experiences in the biomedical sciences led to an interest in evidence-based practices. Ms. Heinzerling began her nursing career as a medical/surgical nurse. Patients in acute care with multiple chronic conditions and repeated hospitalizations inspired her practice of hospice nursing. She has worked as a hospice admissions nurse and a hospice RN case manager in both a large urban setting and a rural community.
Target Audience:
The target audience for this course is: Care and Case Managers; Nursing Personnel; Social Workers; in the following settings: Hospice.
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To earn continuing education credit for this course you must achieve a passing score of 80% on the post-test and complete the course evaluation.
Course Delivery Method and Format
Asynchronous Distance Learning with interactivity which includes quizzes with questions/answers, and posttests.