Weekend Home Health & Hospice Coordinator

Location: St Johnsbury

This job was posted by  :
For more

information, please see:



Job Summary

Responsible for coordinating home care and hospice services on weekend

days and managing a home care and hospice caseload on weekdays.

Coordinates weekend nursing schedules, patient care and intake of

referrals for home care and hospice. Plans, organizes and directs home

care and hospice services and is experienced in nursing, with emphasis

on community health education/experience. Builds from the resources of

the community to plan and direct services to meet the needs of

individuals and families within their homes and communities.

Supervisory Responsibilities

This position has no direct supervisory responsibilities.

Essential Job Functions/Responsibilities

• COORDINATION
• Communicates with the Referral Source to facilitate the process

of admission of the person into the agency.

• Obtains all necessary referral information, including, but not

limited to, physician ordered medications and treatments (signed

by provider) and enters information into electronic medical

record.

• Ensures patient meets eligibility requirement for certain

admission types and if does not, assists referral source with

exploring alternative options.

• Communicates with the patient or family when necessary to give

an accurate description of the services the patient is referred

to.

• Establishes and maintains positive working relationships with

customers and referral sources and responds to customer requests

and concerns.

• Maintains comprehensive working knowledge of community resources

and assists referral sources in accessing community resources

should services not be provided by Northern Counties Health

Care.

• Monitors and responds to weekend tele-monitoring data.
• Responds to calls from the answering service on Saturday and

Sunday, 8am to 4pm.

• Coordinates patient care and communicates scheduling changes to

nurses.

• DIRECT CARE
• Completes an initial assessment of patient and family to

determine home care needs and regularly re-evaluates patient

nursing needs.

• Initiates the plan of care and makes necessary revisions as

patient status and needs change.

• Develops a care plan, which establishes goals based on nursing

diagnosis and incorporates therapeutic, preventive, and

rehabilitative nursing actions. Includes the patient and the

family in the planning process.

• Initiates appropriate preventive and rehabilitative nursing

procedures. Administers medications and treatments as prescribed

by the physician. Provides direct patient care as defined in the

State Nurse Practice Act.

• Counsels and educates the patient and family in meeting nursing

and related needs.

• Identifies discharge planning needs as part of the care plan

development and implements prior to discharge of the patient.

• Acts as Case Manager when assigned by Nurse Manager and assumes

responsibility to coordinate patient care for assigned caseload.

• Participates in care conferences and in-services.
• COMMUNICATION
• Prepares clinical notes and updates the primary physician when

necessary and at least every 60 days.

• Communicates with the physician regarding the patients needs and

reports any changes in the patients condition; obtains/receives

physicians orders as required.

• Communicates with community health related persons to coordinate

the care plan.

• ADDITIONAL DUTIES
• Participates in on-call and holiday duties.
• Ensures that arrangements for equipment a d other necessary

items and services are available.

• Instructs, supervises and evaluates home health aide care

provided in accordance with state and federal regulations.

• The above statements are intended to be a representative summary of the

major duties and responsibilities performed by incumbents of this job.

The incumbents may be requested to perform job-related tasks other than

those stated in this description.*#J-18808-Ljbffr