Registered Nurse Mentor; RN

The home health registered nurse Mentor uses the nursing process (assesses, plans, implements, evaluates) to provide patient care in the home setting and to provide field clinical training to new nursing hires to Home Health. Provides individualized patient care for patients in all developmental stages throughout the life span including Adult (18‑72 years) and Geriatric (72+ years) according to established policies, procedures, guidelines and nursing standards of care.

Provides additional precepting oversight to new hires. This position is responsible for the care and case management of patients in all stages of life in their homes based on the nurse’s experience and competency evaluation.

Utilizing all aspects of the Nursing Process (assessment, planning, implementation, evaluation) with appropriate skill to effectively manage the Plan of Care for each patient as evidenced by:

• Providing nursing intervention based on physiological needs and clinical assessment appropriate for the patient’s age and developmental stage.
• Providing and/or facilitating education according to the Plan of Care and within the level of understanding and developmental age for both the patient and his/her family.
• Providing developmental interventions appropriate to patient’s age and clinical status.
• In collaboration with the patient/family and the physician, the nurse performs and documents a thorough, timely initial assessment to determine the eligibility for home care and to identify needs and problems.
• Reassesses the patient at a minimum of every 60‑62 days or when the patient demonstrates a significant change in clinical status, support system or care environment. Reviews and accurately updates the overall plan of care (CMS 485) at least every 60‑62 days, incorporating all pertinent changes in the physician summary letter, concisely summarizes the significant facts of care and the progress toward achieving goals.
• Obtains physician orders and utilizes data collected during the admission assessment; agency teaching guidelines and appropriate nursing skills to implement and follow an established plan of care. Evaluates and revises the nursing and aide plans of care, when there are changes in the patient’s condition, psychosocial status, and home environment; when no progress toward stated goals is evident and when there is a change in physician orders.

Effectively and efficiently manages the care of a caseload of patients and coordinates care with a multidisciplinary team.

• Supervises the home health aides every 14 days in accordance with federal/state guidelines and agency policy.
• Collaborates with and supervises the nursing care provided by the LPN. Conferences with LPN on shared patients when there are changes in the plan of care or status of the patient.
• Conferences with other disciplines regarding the status of shared patients and consistently documents interdisciplinary coordination and communication activities in the clinical record. Attends interdisciplinary conferences in accordance with agency policy. Makes appropriate notifications in advance of the conference if unable to attend.
• Maintains patient caseload and keeps clinical manager informed of current caseload in accordance with…