22014779What You Will Do Provides, coordinates and directs the provision of home health nursing services and case management processes according to the assigned patient’s individualized plan of care based on agency policies and procedures, through the competent application of nursing process.
Demonstrates knowledge of home care and competency in discipline specific patient care skills, required by the care center for the provision of patient care.
Performs patient comprehensive assessments and collaborates with patient multi-disciplinary care team (PT, OT, ST, MSW, and paraprofessionals) and other health care professionals to develop/modify and implement an individualized patient plan of care as per physician orders that ensures quality, proper discharge planning and achieves desired outcomes and goals.
Implements appropriate nursing clinical programs and initiatives to achieve desired outcomes.
Provides clinical episode management according to Amedisys’ processes including oversight of patient’s individualized plan of care and care plan changes as deemed necessary by patient’s status or physician’s ordered care.
Utilizes a combination of agency resources and nationally recognized standards of practice to deliver high quality care and achieve excellent patient specific outcomes.
Makes referrals to other disciplines as indicated by the patient’s identified needs or documents rationale for not doing so.
Promotes and maintains patient health and independence through teaching and appropriate rehabilitative measures, assisting patients in learning appropriate self-care techniques.
Advocates and ensures patient participation in care planning and goals of care.
Supervises caseload including LPN’s and Home Health Aides.
Facilitates care coordination with PRN staff when care is provided for caseload.
Completes documentation timely, accurately, and at the point of care, according to industry standards, conventions and guidelines, including OASIS assessments, SOC/Admissions, Recertifications, ABNs, subsequent visits, physician orders, care coordination etc.
Helps to achieve and maintain continuity of patient care by communicating information (for example, changes in plan of care, new orders, lab results, etc.) timely, effectively and systematically with all team members providing care for the patient including PT, OT, ST, MSW, paraprofessionals, physicians, family members and community resources.
Facilitates interdisciplinary communication and follow up through care coordination on assigned caseload for duration that patients are on service.
Participates in Team/Case Conferences.
Leads discussion on multidisciplinary cases as appropriate.
Maintains ongoing communication with clinical manager regarding progress of patients for assigned caseload.
Remains knowledgeable of organization’s quality improvement programs, participates in agency performance improvement initiatives and incorporates into patient care planning as appropriate.
Demonstrates competency in skills for required patient care.
Initiates, plans and provides staff education, and performs competency and skills validation for care team staff, such as LPN’s, HHA’s and RN visit staff.
Utilizes a combination of care center resources and recognizes standards of practice to achieve positive clinical and training outcomes.
Utilizes accepted Amedisys teaching materials for clinician and patient/family education.
Performs on-call responsibilities and on-call services to patients/families as assigned.
Monitors assigned cases to ensure compliance with requirements of third-party payers.
Protects, honors, and respects patient and co-worker confidentiality and right to privacy.
Stays informed of industry knowledge and nursing best practice standards.
Participates in clinical development and continuing education programs.
Performs other duties, as assigned.