- Ensures quality and safe delivery of services to patients according to care plan. Uses equipment and supplies safely, effectively, and efficiently.
- Consistently utilizes a holistic approach considering physical, psych/social, spiritual, educational, safety and related criteria appropriate to the age of the patients served in assigned service area.
Provides patient, family, and/or caregiver education and information pertinent to diagnosis and safety issues.
Maintains accurate and timely documentation of clinical records and time and travel entries.
Integrates and coordinates the care of the at-risk population across the healthcare continuum.
Communicates clinical status and plans clearly, succinctly and accurately to interdisciplinary home care team, schedulers, team leaders, and physicians.
Serves as a patient advocate, educator and as central source of communication for the patient and their support systems, and referral sources.
Case conferences with clinical management, physician and interdisciplinary team in order to provide high quality, cost effective care.
Develops a plan of care appropriate to patient acuity/complexity and specific to the individual needs of the patient.
Care is outcome-oriented, reflects measurable progress and goals toward discharge.
Is responsible for case management of the patient during the home care episode including updating the patient’s plan of care, discharge planning, advocacy for patient needs and delegating to others as appropriate.
Is responsible for oversight of the care delivered by other nurses and home health aides during the episode of care.
Facilitates advance care planning discussions to ensure appropriate care coordination and high-quality care based on patient’s long-term goals of care.
Delivers quality care consistent with Home Health Conditions of Participation, qualifying home care criteria, payor coverage criteria, and providing visits/treatments consistent with the plan of care.
Conducts clinical review of record to include multi-disciplinary review, coordination of care, provided in conjunction with visits and documentation.
Identifies risk for acute hospitalization and proactively prevents adverse events.
Demonstrates competency in comprehensive assessment/OASIS competency without oversight.
Maintains OASIS accuracy and integrity by reviewing all audits and reviews and making changes as necessary in a timely manner.
Responsible for accurate documentation (ie: care plan within required timelines, care and utilization of resources to achieve quality outcomes, conferences, discharges, billing, coding.)
Documentation reflects understanding and application of qualifying criteria for home care.
Reviews multidisciplinary care provision, conducts own clinical review and participates in peer audit, as applicable.
Assists in the promotion of services and products.
Maintains regular and consistent attendance at work.
Behaves in a manner consistent with Mission, Vision and Values..
Maintains compliance with OSHA, Accreditation Standards, and Risk Management guidelines.
Maintains compliance with Personnel policies and procedures.
Behaves in a manner consistent with all Corporate Compliance policies and procedures.
Performs other duties as requested by the Clinical Manager or Clinical Supervisor to facilitate smooth and effective operations of the organization.
Meet or exceed agency established benchmarks for quality and process measures, patient satisfaction, OASIS case mix, productivity and documentation timeliness.
Employee is responsible for professional communication with all members of the interdisciplinary team and home care operations. This includes but is not limited to responding to email, voicemail and telephony message; attending all required staff meetings; communicating with supervisor and other team members; reviewing all employee communication; and reviewing department newsletters.