Initial and ongoing comprehensive assessments of the impact of the terminal
disease on the patients physical, functional, psychosocial, and environmental
needs and ADLs, i.e., risk for grief, cultural/spiritual.
The registered nurse plans, organizes and directs home care services and is experienced in nursing, with emphasis on community health education/experience.The professional nurse builds from the resources of the community to plan and direct services to meet the needs of individuals and families within their homes and communities.
The primary responsibility of the case manager is to identify, screen, track, monitor and coordinate the care of patients with multiple co-morbidities and/or psychosocial needs and develop a case management plan of care.