Home care LPN Intake Coordinator

The LPN Intake Coordinator/Educator is responsible for coordinating all new referrals made to the agency, ensuring that all new referrals meet the agency's policies and procedures as well as federal/state regulations and guidelines.

• Maintains working knowledge of current home health coverage guidelines, admission criteria, documentation requirements, coding guidelines, and care planning with case conferences; manages patient care accordingly.
• Effectively manages initial home visit; introducing services, admission criteria, the process for determining patient eligibility, and obtaining required consents when eligibility is confirmed.
• Assess the patient/caregiver's willingness, ability, and barriers to learn patient care techniques and for achieving independence in care; documents patient and family response to teaching.
• Outlines aide care plan; performs ongoing home health aide oversight, revises aide care plan based on patient progress; evaluates home health aide care every 14 days or per state payer requirement and state regulations.
• Supervises CAN participation in patient's plan of care and performance of skilled interventions at intervals defined by state regulations.
• Initiates the plan of care and related nursing interventions; conducts goal-oriented visits; ensures other nursing team members have the information needed for continuity of care and continued progress.
• Provides patient/family teaching per POC; assesses and documents response to teaching.
• Advocates for the patient as required.
• Completes an accurate, initial comprehensive head to toe assessment. Completes for home health patients, an OASIS, and other assessments of patient and family to determine home care needs; obtains a history of current and previous illness(es).
• Uses health assessment data, input from agency team members, the physician, patient and family, to determine patient needs.
• Effectively manages patient and family expectations regarding agency services, outcomes/discharge goals and ability to achieve independence in care.
• Establishes appropriate primary and secondary diagnosis based on patient assessment and focus of home health care.
• Develops a care plan, incorporating appropriate skilled interventions, and necessary medical supplies/equipment and ancillary/specialty services, to achieve outcome/discharge goals.
• Protects realistic home health visits by discipline and medical supplies required per planned interventions and discharge goals. Write POC orders accordingly.
• Regularly evaluates home health patient's progress, in collaboration with team members; revises patient POC accordingly.
• Performs ongoing appropriate OASIS assessments and revises POC accordingly.
• Identifies home health patients' discharge planning needs when developing the plan of care; identifies and implements community referrals before patient discharge; determines patient readiness for discharge based on expected outcomes, goals, and coverage guidelines.

• Prepares clinical notes and other required documentation within the required time frames.
• Obtains/receives physician orders as required for treatment changes; communicates new/changed orders to appropriate team members.
• Tracks all assigned cases, and organizes schedules to ensure all patients' needs are met per their individual POC.
• Meets agency productivity requirements
• Requests PTO in advance per agency protocol
• Communicate with the Clinical Supervisor regarding the coordination of the plan of care, need for overflow, weekend, and after-hours nurse assignments.
• Ensures the availability of equipment/supplies and other necessary items to support care plans; uses equipment/supplies per plan of care and documents per agency policy.
• Provides instruction for other team members
• Provides updates for the primary physician when necessary and at least every sixty days.
• Facilitates ongoing care discussions and team case conference discussions of the patient goals, progression, and needs for ongoing care, and revises goals and/or interventions to enhance patient progress toward discharge.
• Plans and coordinates assignment of clinical staff to clients with input from the Home Health Director, Administration,…