Overview
Job Summary Serves a case management role, responsible for an assigned group of patients, typically geographically related and accountable for the oversight and overall management of the post-acute services in the home setting. Provides direct patient care and supervision of LPNs and HHAs in accordance with an established plan of care to address the patient needs, individual goals and physician ordered services. Responsible for care coordination with the assigned multi-disciplinary team and acts as the assigned patient's liaison with other related healthcare providers in the continuum of care. Ensures appropriate, qualified and timely patient care and documentation in order to meet patient needs and agency financial, operational, and quality goals.
Essential Functions
Responsible for the daily management of an assigned patient caseload, ensuring timely care and documentation to meet the patent needs/services as prescribed in the established plan of care and per MD orders
Collects data pertinent to the healthcare consumer's health or the situation from patient assessments in the home setting, telephonic contacts and/or related EMR information available.
Analyzes the data to determine the issues and available resources to seek effective resolution. Identifies patients at high risk for re-hospitalization, falls and/or high utilization of resources that require additional intervention and case conferencing to ensure appropriate care and frequency of services mitigates risk and ensure high quality outcomes
Prioritizes multi-issue, situations appropriate to the criticality of patient health and welfare, patient/staff safety and impact to effective, timely services
Identifies barriers to situation/complaint resolution (i.e. language, literacy, psychological, etc) and follows-up with the appropriate resources or leadership to address timely and effectively
Develops and provides oversight of a plan of care that is effectively communicated with the parties involved and supports quality patient outcomes and patient satisfaction.
Implements the identified plan, and directs the care coordination of a multidisciplinary clinical team approach, supervision of LPNs and/or HHAs involved in the care of the assigned patient caseload to promote health and safe outcomes.
Performs ordered treatments, therapies, and/or procedures in accordance with State Nurse Practice Act and Home Health Conditions of Participation, JCAHO and agency policy and procedures.
Evaluates progress towards attainment of patient centered goals.
Physical Requirements Work requires walking, standing, sitting, lifting, reaching, stooping, bending, pushing, and pulling. Must be able to lift and support the weight of 35 pounds in handling patients, medical equipment, and supplies. Must speak English in good, understandable terms. Intact sense of sight, hearing, smell, touch. Finger dexterity. Critical thinking and ability to concentrate. Must be able to respond quickly to changes in patient conditions. Physical Abilities Testing required.
Education, Experience and Certifications Graduate from an accredited School of Nursing. BSN preferred. BLS required per policy guidelines. Current RN license or temporary license as a Registered Nurse Petitioner in the state in which you work and reside or; if declaring a National License Compact (NLC) state as your primary state of residency, meet the licensure requirements in your home state; or for Non-National License Compact states, current RN license or temporary license as a Registered Nurse Petitioner required in the state where the RN works. Additional education, training, certifications, or experience may be required within the department by the nurse leader.