Provides, coordinates, and directs the provision of home nursing care according to physician’s orders based on agency policies and procedures, through the competent application of the nursing process.
• Demonstrates knowledge of home care and competency in discipline specific patient care skills, required by the care center for the provision of patient care.
• May be assigned RN visits as member of care team, and/or may be required to supervise a patient caseload, including LPN’s and HHA’s.
• Performs patient comprehensive assessments, as assigned, and collaborates with patient multi-disciplinary care team (PT, OT, ST, MSW and paraprofessionals) and other health care professionals to develop/modify and implement an individualized plan of care as per physician orders that ensures quality, proper discharge planning and achieves desired outcomes and goals.
• Helps to achieve and maintain continuity of patient care by communicating information (for example, changes in the plan of care, new orders, lab results, etc) timely, effectively and systematically with all team members providing care to the patient. Facilitates interdisciplinary communication and follow-up through care coordination on assigned patients and/or caseload of patients for duration they are on service.
• Provides patient episode management per company protocol.
• Makes referrals to other disciplines as indicated by the patient’s needs or documents rationale for not doing so.
• Utilizes a combination of care center resources and rationally recognizes standards of practice to achieve positive clinical outcomes.
• Participates in clinical outcomes monitoring, follow up and care center performance improvement initiatives.
• Initiates, plans and provides staff education and performs competency and skills validation for staff as needed.
• Utilizes accepted company teaching materials in patient/family education.
• Regularly communicates patient progress to the clinical manager.
• Completes documentation timely, accurately, and at the point of care, according to industry standards, conventions and guidelines, including OASIS assessments, SOC/Admissions, Recertifications, ABN’s, subsequent visits, physician orders, care coordination, etc.
• Performs other duties as assigned.