Acute​/Post Acute Field RN

Woburn, MA
• Beth Israel Lahey Health at Home
• Full-time
• Day When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives.

The registered nurse plans, organizes and directs home care services and is experienced in nursing, with emphasis on community health education/experience. The professional nurse 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 in accordance with home care regulations, hospital regulations and payer guidelines. The registered nurse is also trained in caring for Acute Hospital Care at Home patients, delivering care in the patient’s home, in partnership with the Command Center multidisciplinary clinical team.

Job Description:

Essential Duties & Responsibilities including but not limited to:

Patient Care
1. Assumes responsibility to coordinate patient care for the temporarily assigned caseload including but not limited to: appropriate delegation to LPN staff, patient condition change visits, and completion of OASIS time points. Accepts accountability for patient satisfaction scores and quality of care outcome measure results.
2. Completes and documents an initial assessment of patient and family to determine home care needs. Provides a complete physical assessment and history of current and previous illness(es).Develops a patient specific plan of care, 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.
3. Initiates the plan of care and makes necessary revisions as patient status and needs change.
4. Initiates appropriate preventive and rehabilitative nursing procedures. Administers medications and treatments as prescribed by the physician.
5. Counsels the patient and family in meeting nursing and related needs.
6. Respects and supports patient and family’s cultural beliefs and values, individual needs, health goals and treatment preferences.
7. Provides health care instructions to the patient as appropriate per assessment and plan of care.
8. Instructs, supervises and evaluates home health aide care provided every two (2) weeks.
9. Helps manage episode of care or coordination of care with the primary disciplines in accordance with evolving occupational therapy needs and continued eligibility for services.
10. Identifies discharge planning needs as part of the care plan development and implements prior to discharge of the patient.

Communication
1. Communicates with the physician regarding the patient’s needs and reports any changes in the patient’s condition; obtains/receives physician’s orders as required.
2. Attends regular case conferences and team meetings per Clinical Manager and as needed.
3. Communicates with team LPN when delegating appropriate visits.
4. Communicates with other disciplines on the care team and community providers to coordinate the care plan (i.e. Insurance case managers, high risk case managers, elder services, protective service, etc).5. Practices confidentiality principles set by the agency and federal HIPAA guidelines.

Documentation
1. Demonstrates proficiency in OASIS completion
2. Clinical visit notes explain the need for the skilled nursing service in light of the patient’s overall medical condition and experiences; the complexity of the services performed and the plan for the next visit based on the rationale of prior results.
3. Completes documentation in accordance with agency timeliness policies.

Hospital at Home Responsibilities:

Essential Duties & Responsibilities including but not limited to:

Clinical

Roles and Responsibilities:

Maintain clinical practice in accordance with hospital regulations regarding assessment, care coordination, treatment interventions and documentation for diverse patient populations fitting the Acute Hospital Care at Home model.o Participate and complete Mandatory Education related to inpatient clinical care pertinent to Acute Hospital Care at Home patients as assigned by leadership.

Admit patients transferred to Hospital at Home in accordance to…