$10,000 Sign On Bonus for external candidates

The Home Care RN uses clinical nursing knowledge, physical assessment, teaching and procedural skills to deliver high quality patient care in the patient’s place of residence. The RN contributes to the development of the home health plan of care. The RN delivers patient care directed by the physician as established in the home health plan of care that is consistent with clinical best practices and results in high quality, improved outcomes and exceptional patient experience.

Patient Care/Care Coordination

• Makes visits to the homes of patients requiring home health nursing services and assumes responsibility for an ongoing interdisciplinary assessment of the patient.
• Performs initial and comprehensive assessments on all patients in accordance with agency policies and procedures.
• Performs nursing assessment at each visit in accordance with agency policies and procedures.
• Ensures quality and safe delivery of services to patients according to the care plan.
• Uses equipment and supplies safely, effectively, and efficiently.
• Promotes patient independence by teaching patients and family members to understand the following as well as any additional education needs identified by the assessing clinician and/or physician:
  • Treatment and disease management
  • Medications purpose, use, side effects, potential adverse effects
  • Proper use, safety hazards, and infection control issues related to the use and maintenance of any equipment provided
  • Patient plan of care
  • Emergency preparedness
• Provides the services that are ordered by the physician as indicated in the plan of care managed by the RN Case Manager.
• Provides patient, caregiver and family counseling and education as indicated in the plan of care.
• Assists the RN Case Manager in the development and ongoing update to a plan of care that specifies the care and services needed to meet patient-specific needs determined during the comprehensive assessment and includes measurable outcomes that will occur as a result of implementing and coordinating the plan of care.
• Develops and updates patient’s discharge plan on every visit ensuring patient and caregiver education and training is facilitating timely discharge and measurable goals and outcomes are attainable, realistic and up-to-date.
• Includes the patient, representative and caregiver in all plan of care decisions.
• Assesses for the need to update the current plan of care and includes the patient and family in care planning decisions and communicates care plan revisions to the patient, representative, caregiver and all physicians issuing orders for the home health plan of care.
• Communicates patient changes and/or concerns to the RN Case Manager and participates in care coordination to achieve high quality care.
• Maintains accurate and timely documentation of clinical records and time/travel entries.
• Receives, relays and documents verbal orders in accordance with state and federal regulations and in a timely manner to prevent adverse patient outcomes.
• Is responsible for obtaining physician orders prior to initiation of care and notifying the physician of any changes in the patient’s condition.
• Communicates with all physicians involved in the plan of care and other health care practitioners related to the current plan of care.
• Identifies patient’s risks for hospitalization and/or emergency department use and proactively intervenes to prevent adverse events.

Home Care Performance Criteria

• Delivers quality care and completes clear, concise and accurate clinical documentation of care provision in accordance with home health conditions of participation (CoPs), various payer home health coverage criteria, accreditation standards, professional standards for discipline/credential and the home health plan of care.
• Maintains competence in OASIS data collection and documentation and submits all initial and corrected assessments according to CMS guidance and agency policies and procedures.
• Participates in clinical review of records to monitor quality and accuracy, appropriate utilization, appropriate involvement of interdisciplinary team members, appropriate referrals and coordination of care.
• Participates in peer review and other quality assurance activities, as assigned.
• Uses appropriate infection control procedures and safety measure to protect employees and patients.
• Provides patient and family education using UPaH approved patient teaching materials only.
• Participates in case conferences, in-service programs and other meetings required to ensure coordinated and comprehensive care.
• Reviews all patient assignments prior to scheduling first visit and accepts patient assignments only for which qualified and competent in any specific care/technical skill/procedure needed.
• Participates as a member of the interdisciplinary team.
• Participates in quality assurance/performance improvement (QAPI) activities, as assigned.
• Maintains professional knowledge for discipline/credential/license ensuring inclusion of content specific to home and community based care.
• Communicates professionally, effectively and timely to all team members and co-workers and responds to all communication in a timely manner including, but not limited to e-mails, phone communication and meeting follow-up responsibilities.
• Establishes and maintains positive interpersonal relationships with team members, patients and family members while maintain personal and professional boundaries.
• Assist with new employee orientation when necessary.
• Effectively plans, organizes, sets priorities and completes works assignments with minimum direct supervision per agency policy and within established time frames.
• Maintains productivity standards as defined by home care supervisor.
• Participates in evening, night and weekend coverage to ensure nursing services are accessible to all patients 24 hours a day, 7 days per week (schedules and rotations determined by region).
• Performs other duties as assigned by home care clinical supervisor and/or administrator.Supervises home health aide and licensed practical nurse staff and documents supervision in the patient medical record.

QUALIFICATIONS: