PURPOSE OF THIS POSITION:
The RN will coordinate the home care of chronically ill patients by utilizing a disease management process, the OASIS assessment, plan of care and established protocols. Will also educate the patient/caregiver in the management of their illness and promote the home health support systems to decrease re-hospitalization and utilization of hospital emergency services.
PRIMARY DUTIES AND RESPONSIBILITIES:
- Review the home health referral, updating & communicating any changes to other disciplines and to customer service center.
- Perform assessments within 24-48 hours of receiving a referral.
- Complete Start of care papers and forward to the office promptly.
- Develop rapport with the client and family ensuring privacy and confidentiality while obtaining accurate client history.
- Complete a physical assessment and communicate the findings and plan of care to the physician.
- Initiate evaluations to other disciplines (PT,OT,HHA,SLP,MHRN,MSW) or support services when indicated.
- Conduct Home health aide supervisory duties as required by state regulations.
- Document accurately and appropriately on the laptop during each visit, uploading by midnight.
- When appropriate, enter insurance authorization requests within 24 hrs of initial evaluation and continue to enter additional requests at the end of each authorization period.
- Organize daily assignments, setting priorities based on individual and overall needs of the clients while traveling to each home as scheduled.
- Ensure the clients have prescribed medications and/or treatment supplies, updating file as changes occur.
- Identify appropriate actions that will provide for continuity of care, an individualized teaching plan and the involvement of the individual and family/caregiver whenever possible.
- Formulate a plan of care to achieve expected outcomes through short and long term goals that are realistic and feasible in terms of resources, time, material, people and cultural relevancy. Revise the plan of care in response to changes in the individual's status or to adjust to the individual's response to care, and communicate and update with all disciplines, including PPL.
- Coordinate discharge planning with direct involvement of client, family/caregiver.
- Document any communication and/or orders from the physician.
- Attend PCH/ALF case conferences as scheduled providing weekly client reports to team and provide PCH/ALF monthly educational inservices as requested by facility.
- Maintain a high level of competency, growth and development, including ensuring license and CPR are current and in good standing at all times.
- Attend nursing staff meetings, quarterly educational in-services and yearly competency day.
- Perform on-call duties per agency requirements/assignment for non-business hours. Position may require after hours patient visits to achieve positive patient outcomes.
- Follows agency policies and procedures as per the Policy and Procedure site of the Celtic Information Portal.
- Adhere/assist with company outcome goals as indicated by QI/home health compare tracking.
- Follow guidelines as indicated in employee handbook.
- Participate in QA/OBQI initiatives with problem-solving via action items.
- Thorough knowledge of and strict adherence to AHN Healthcare@Home’s Mission, Vision, and Core Values.
- Perform other duties as assigned by management.
Licensed RN or BSN with current state license;
Professional license in other states may be requested;
One year prior nursing experience required;
Ability to work independently and within a multidisciplinary team;
Valid driver’s license, required.