Intake Coordinator; LPN

Patient Care

• 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.
• Assesses 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, and Physician as needed.
• Works cooperatively with other staff members in coordination of patient care services and disciplines.
• Acts as liaison between clinical staff and community health care providers by communicating changes in patient status and care as appropriate.
• Evaluates potential referrals, including review of facility documentation.
• Becomes aware of Level of Care issues related to home care, and familiar with insurance reimbursements.
• Participates and assists in case conferences, in-services, and meetings as needed.
• Works with personnel or other community agencies involved in the client's care as directed by the Home Health Services Director and Administrator.
• Coordinates with agency Team Coordinator/Staffing Specialists insuring appropriate staffing coverage for new referrals.
• Coordinates with agency RN Case Managers and clinical staff to assure efficient admission of new referrals.
• Ensures effective and timely coordination of client home care services through the timely completion of required documentation and computer data entry for new…