RN Homecare Clin HEART Team Medical Home Care Exp

General Summary of Position

The primary responsibility of the RN Homecare Clinician- HEART Team is to provide professional nursing services to beneficiaries on the HEART Team. The HEART Team Service is a holistic, interdisciplinary, community based medical and behavioral health service designed to help beneficiaries manage complex medical and behavioral health illnesses. It aims to restore health, improve community, daily living, personal, and social skills while reducing incidence of medical or behavioral health crises that lead to unnecessary use of the hospital system.

• In collaboration with HEART Team, identifies comprehensive learning needs of designated patients. Develops teaching plans that specify time frames. Bases teaching and counseling plan on patient's level of knowledge, diagnosis, prescribed treatment, and available resources. Utilizes demonstration, verbal, and written instruction in order to carry out the care plan. Evaluates the effectiveness of the teaching plan in meeting patient/family goals. Revises as needed.
• Performs history and assessment related to an episode of patient illness. Identifies primary patient problems from assessment. Identifies discharge planning needs. Interprets abnormal clinical data to anticipate problems associated with changing patient status.
• Analyzes and documents patient and family's responses to interventions. Evaluates measurable progress toward goals. Identifies and modifies underlying factors that impede progress toward goals. Makes recommendations for updates in the plan of care, using knowledge of interventions and resources.
• Collaborates with the patient's physician and staff in planning and evaluating patient care. Provides timely, pertinent written and verbal information to physicians and HEART Team members.
• Uses a wide variety of community and agency resources as needed to meet patient needs. Manages activities of caseload mix for patients. Organizes patient assignments for completion of tasks within acceptable time frames.
• Implements and documents plan of care for patients with a routine to complex problems to facilitate continuity of care. Documented interventions are related to the planning of care. Interventions reflect the standard of care for patient condition/diagnosis. Interventions include utilizing agency and community resources. Performs nursing procedures consistent with home care protocols. Interventions reflect knowledge of standard home care supplies and equipment used in inpatient care.
• Is responsive to and communicates respectfully with patients/families, HEART Team members, and other health team members. Participates in regularly scheduled caseload consultation; includes all disciplines. Includes patient and family in mutual goal setting and recommended care plan revision.
• Contributes to the achievement of established goals and objectives and adheres to department policies, procedures, quality standards, and safety standards. Completes annual Code of Conduct, Compliance, and other mandatory training. Complies with governmental and accreditation regulations.
• Maintains effective working relationships with other departments and participates in multidisciplinary quality and service improvement teams. Participates in meetings and on committees and represents the department and agency in community outreach efforts. Enhances growth and development and enriches personal knowledge and skill through participation in educational programs and affiliations. Remains solution focused at all times.
• Drives and travels to community locations, various agencies, and other outreach destinations.
• Provides services remotely, in-office, telephonically, via telehealth, in the community, or beneficiary's home as beneficiary needs and preferences dictate.

• Vocational/Technical Diploma graduation from a diploma program in Nursing required or
• Associate's degree in Nursing required or
• Bachelor's degree in Nursing (BSN) required

• 1-2 years RN experience- diabetes, CHF, COPD, HTN, required
• 1-2 years Home health nursing experience or successful completion of LPN to RN competency assessment preferred
• 1-2 years Mental Health experience preferred

• RN - Registered Nurse - State Licensure and/or Compact State Licensure Valid License in Maryland Upon Hire required and
• CPR - Cardiac Pulmonary Resuscitation Upon Hire required and
• DL - Valid State Driver's License in good standing Upon Hire required

• Phlebotomy experience
• Wound care esperience
• Excellent oral communication, writing, organizational skills and abilities.
• Problem Solving
• Basic computer and Microsoft Office skills.
• Electronic Health Record experience

This position has a hiring range of $74,214 - $134,596