Location: Eureka, CA
Schedule: Full time, 80 hours bi-weekly
Shift: 8 hour, Day
Provides professional nursing care visits in the home care setting and directs home health services for caseload of patients and their families in accordance with physician’s orders through direct care, supervision and multidisciplinary team coordination. Collaborates with other members of the patient care team. Teaches and supervises the family and other members of the nursing team. Supervises the Home Health Aide and Licensed Practical Nurse on assigned caseload.
- Performs the initial and ongoing assessment of patient needs and appropriateness for home care; creates and maintains an individualized goal/outcome based care plan based on the physician’s plan of care.
- Completes accurate and current initial medication profile and maintains ongoing updates of the drug profiles in the medical record and home for assigned patients.
- Provides skilled nursing care based on the plan of care, authorizations and physician orders on assigned patients; adheres to agency policies and procedures for nursing, infection control, bio-hazardous waste management, quality improvement activities, safety and risk management practices.
- Confers with the physician in developing and revising the plan of care; reporting patient progress status; obtaining and documenting additional orders based on the initial and ongoing assessment of the patient progress; following regulatory guidelines and policies in writing orders.
- Ensures that the plan of care includes teaching related to health maintenance and prevention of complications, safety and interventions to achieve patient outcomes.
- Provides care coordination for assigned cases by communicating patient progress, patient/family needs and status changes to the physician, appropriate team members and/or Clinical Manager.
- Makes ongoing nursing assessments, evaluates patient progress, updates the plan of care based on findings, and reports significant changes in the patient’s condition to the physician, appropriate team members and/or Clinical Manager.
- Supervises the Home Health Aide and Licensed Practical Nurse assigned to cases to ensure plan of care is progressing towards achieving patient outcomes.
- Maintains patient caseload for case management; coordinates care activities among all disciplines on the care plan by participating actively in case conferences and discharge planning acting as a resource and liaison with community, multidisciplinary team and other resources to achieve patient outcomes.
- Maintains patient schedules based on orders and authorizations within the Medicare week; submits caregiver schedules timely and accurately; meets productivity standards demonstrating effective time management skills (i.e., contacting the patient the day before to pre-plan visit).
- Maintains daily communication with Team Coordinator providing update to visit activities and changes.
- Accurately and thoroughly documents patient care observations, interventions, supply utilization and evaluations; prepares and submits completed documentation of the home care visit within the established time parameters.
- Participates in the quality improvement and utilization review activities of the organization.
- Maintains working knowledge of and refers patients to community resources as appropriate.
- Reports daily to the Clinical Manager; participates in on-call rotation as scheduled.
- Exhibits good written and verbal communication.
- Attends staff meetings and in-services.
- Completes in-service on blood-borne pathogens annually, annual clinical competencies and other required activities and competencies.
- Demonstrates a high degree of commitment to professional development, customer service and quality care provision.
- Participates in staff meetings, performance improvement activities and clinical record review.
- Completes annual competencies and all required certifications.
- Performs other duties as assigned or requested such as on-call.
Education: Graduate from accredited school of nursing
Experience: Infusion, veni-puncture and or pediatric skills preferred; minimum of one year nursing experience; prefer home care experience.
Training: CPR certification
License/Certification: Current licensure in California