Patient Care

• Provides professional nursing care by utilizing all elements of nursing process and as defined in the state Nurse Practice Act.
• Develops a care plan that establishes interventions and goals. Includes the patient and the family/caregiver in the planning process.
• Works with intake, clinical manager, and/or DPS to coordinate patient start of care in a timely manner.
• Educates patient/caregiver regarding regulatory components for home health admission. Documentation of this education will be completed in the patient’s medical record.
• Obtains consents for home health services.
• Completes an initial comprehensive assessment of patient and caregiver/living situation to determine care needs.
• Completes a comprehensive medication review and reconciliation.
• Sets up an individual emergency preparedness plan.
• Establishes the initial individualized plan of care in collaboration with the certifying medical provider based on comprehensive assessment and patient goals.
• Admission documentation is completed within 24 hours.
• Attends required staff meetings, interdisciplinary team meetings and care coordination activities

Additional Duties

• Participates in on-call duties as defined by the on-call policy.
• Ensures that arrangements for equipment and other necessary items and services are available.
• Supervises ancillary personnel and delegates responsibilities when required.
• Coordinates patient care in tandem with Case Manager as assigned by Clinical Manager.
• Assumes responsibility for personal growth and development and maintains and upgrades professional knowledge and practice skills through attendance and participation in continuing education and in-service classes.
• Fulfills the obligation of requested and/or accepted case assignments.
• Actively participates in quality assessment performance improvement teams and activities or other committees as assigned
• May be required to work outside of designated geographical area based on census fluctuations and current staffing.
• Completes mandatory education requirements annually to maintain competence.
• May be required to visit patients in homes that are not clean, or in poor repair, have poor ventilation, are infested with insects or rodents, and secondhand smoke.
• Driving conditions may be difficult related to weather and/ or traffic.
• Maintains knowledge of and adheres to all applicable laws, rules, and standards.
• Participates in the orientation of new employees and preceptorship of students as assigned.
• Meets productivity expectations.

• Completes ongoing comprehensive assessment of patient and family to determine care Provides a complete physical assessment and history of current and previous illness(es).
• Assesses and evaluates patient’s status by:
  • Regularly re-evaluating patient and family/caregiver needs.
  • Participating in revising the plan of care as patient status and needs change in collaboration with the certifying medical provider.
  • Develops a care plan that establishes preventative and rehabilitative nursing procedures. Includes the patient and the family/caregiver in the planning process.
  • Develops a care plan that establishes interventions and goals. Includes the patient and the family/caregiver in the planning process.
  • Works autonomously to initiate appropriate preventive and rehabilitative nursing procedures. Administers medications and treatments as prescribed by the medical provider in the plan of care.
  • Involves the patient and family/caregiver to address needs and meet related goals.
  • Provides health care instructions to the patient as appropriate per assessment and plan.
  • Facilitates the patient’s efforts toward self-sufficiency or obtaining appropriate caregiving.
  • Acts as Case Manager when assigned by Clinical Manager and assumes responsibility to coordinate patient care for assigned caseload.

Communication

• Documents patient services and status timely and accurately within professional practice standards and reimbursement requirements.
• Records pain/symptom management changes/outcomes as appropriate.
• Communicates with the medical provider regarding the patient’s needs and reports changes in the patient’s condition; obtains/receives medical provider orders as required.
• Teaches the patient and family/caregiver self-care techniques as appropriate. Provides medication, diet and other instructions as ordered by the medical provider and recognizes and utilizes opportunities for health counseling with patients and families/caregivers. Works in concert with the interdisciplinary team.
• Assists the patient and family/caregiver and other team members in providing continuity of care.

• Graduate of an accredited school of nursing. One (1) to two (2) years of recent acute care experience in an institutional setting, and one (1) to two (2) years of recent experience in home health preferred.
• Current licensure in State(s) of planned practice and CPR certification.
• Must be a licensed driver with an automobile that is insured in accordance with state and/or organization requirements and is in good working order.
• Excellent observation, verbal and written communication skills, problem solving skills, basic math skills; nursing skills per competency checklist.
• Self-directed and able to work with minimal
• Capable of prolonged or considerable walking or standing. Able to lift, position and/or transfer patients. Able to lift supplies and equipment. Capable of considerable reaching, stooping bending, kneeling, and/or crouching. Possesses visual acuity and hearing to perform required nursing skills.