The purpose of positions in this classification is to provide skilled nursing care to home care or hospice patients and to coordinate the patients plan of care for all disciplines and services under the direction of the Home Care Clinical Manager and physician.
This listing is not to be construed as all-inclusive. Other duties may be required and assigned.
Travels to patient homes and provides skilled nursing care within the established plan of care. Provides direct patient care including performance of tasks such as taking vitals, performing wound care, IV care, ostomy care, blood draws, injections, and the physical assessment of the overall patients medical condition. Reviews, sets-up, and administers medications as necessary per the established plan of care. Continually evaluates the patients condition and the effectiveness of treatments, plan of care, medications, and therapies.
Coordinates the patients plan of care for nursing, therapy, social services and other disciplines and services from the initial assessment to end of care under the direction of the Home Care Clinical Manager and physician. Conducts patient admissions. Ensures that patient assessments and reassessments are completed in a timely and accurate manner. Develops patient-specific goals. Evaluates outcomes of care. Assists in identifying barriers to achievement of identified patient goals and works in collaboration with the Patient Care Manager and other patient care team members to assure coordination of care is provided to attain desired outcomes.
Contacts and consults with the physician regarding the plan of care. Communicates significant changes in patient condition. Provides regular updates on progress and recommends revision of plan care. Recommends patient for further medical attention as needed.
Responsible for the discharge of patients. Ensures the discharge summary is complete and accurate. Coordinates the transfer of patients to external agencies in collaboration with the interdisciplinary.
Documents visit notes, treatments, and care. Records and reports symptoms and changes in patients condition. Completes and transfers data on a timely basis. Verifies that physician orders for all disciplines are complete, accurate and cover the care and visits provided. Ensures orders are obtained prior to service delivery. Documents any verbal orders and follows up to secure written orders. Follows visit pattern according to physicians orders and ensures required visits are completed in a timely manner. Documents patient refusal of visits or care.
Provides information, instruction and education to the patient, patient family members and caregivers in proper care. Verifies that instructions are being followed and carried-out.
Responds to calls from patients, family members and others and provides appropriate follow-up to address needs, issues, or concerns.
Provides instruction and direction to Home Health Aides (HHA) and Licensed Practical Nurses (LPN) staff. Monitors and reviews the provision of care provided by the HHAs and LPNs and communicates concerns to the Home Care Clinical Manager. Provides instruction and training as necessary. Reviews documentation to ensure compliance to the plan of care. Timely completion of joint visits.
Responsible for attending to patient after death or discharge. Ensures the death or discharge summary is complete and accurate. For discharge, coordinates the transfer of patients to external agencies in collaboration with the interdisciplinary team.