Staff Nurse - Home Health - Per Diem

Summary
The Home Health Nurse works under the general direction of the Director, Clinical Manager, and the Provider to provide skilled nursing assessment, planning, and care in compliance with the interdisciplinary group plan of care. The Home Health Nurse assumes primary responsibility for case management of patient/family caseloads. This position has responsibility for the assessment, treatment, and care of Home Health patients of all ages.

Essential Duties and Responsibilities

Data Collection:

Assesses the knowledge and expectations and reactions of patients/families referred to Home Health and compliance with the plan of care.

• Completes the initial clinical nursing/medical Home Health OASIS assessment, according to Nurse Practice Act and Home Health Regulatory Compliance.
• Obtains and synthesizes necessary data from the patients medical record, patient and family, physician conference etc. and incorporates data into the electronic medical record.
• Maintains patient electronic medical records to reflect current problems, plans, interventions and goals in accordance with regulatory requirements and departmental policy and procedures.
• Collaborates with physicians and team members to determine appropriate frequency of nursing visits, need for a change of level of care, attendant care training, interruptions related to in-patient admissions, and discharge from Home Health once goals are met.
• Demonstrates advanced assessment skills specific to Home Health patient population.

Planning:

Demonstrates effective planning to meet needs of patients in caseloads as needed.

• Ongoing nursing documentation demonstrates dynamic use of plan of care to reflect the addressing of high priority problems identified by patient/family or the Home Health team.
• Accurately completes and updates the Plan of Care.

Intervention:

Makes recommendations to the Home Health team for interventions and follow-up.

• Interventions reflect an advanced level of nursing practice and commitment to the execution of the plan of care.
• When functioning as on-call nurse, utilizes expert knowledge of Home Health care, crisis intervention, and family dynamics to determine necessity for home visits. Is able to demonstrate effective communication and intervention in meeting patient/family needs in the home environment.
• Uses nursing judgment and functions as patient/family advocate, in collaboration with all the members of the Home Health team including the primary care physician, when seeking change in optimal care setting for the patient, incorporation patient safety and family care giving ability.

Evaluation:

Evaluates appropriateness of patient/family referral to Home Health, in collaboration with other core members of the Home Health team including a therapies, medical social worker and the physician.

• Evaluates response to the plan of care and alerts the team of need to reevaluate plan of care.
• Evaluates needed frequency of home nursing visits on all patients.
• Participates in quality assurance activities as indicated.

Continuity of Care:

Documents current plan of care on if patient patient requires change of service or is discharged from Home Health Services.

Interdisciplinary Collaboration/Communication:

Communicates Home Health expectations and plan of care to the patient/family.

• Communicates with attending physician, team members and other agencies as needed to coordinate optimal care and optimal use of resources for the patient/family.
• Makes independent decisions regarding nursing care and can support these decisions based on assessment and clinical knowledge. Collaborates with physician, Medical Director and other team members to evaluate patient's response to and need for care.
• Supervises and documents the Certified Home Health Aide plan of care every two weeks.
• Attends bimonthly Case Management meetings and actively participates in all discussions related to patient care.
• Recognizes the knowledge and skills of other disciplines represented on the team and advocates for the most appropriate team member's intervention with the patient/family.

Professional Development:

Teaches needed aspects of care as appropriate for home health aides.

• Meets regularly with Home Health…