***Please note: internal applicants only***
Under the direction of the Homecare Services Clinical Manager/Clinical Supervisor performs the specific clinical duties of the Homecare Nurse, including the case management of comprehensive services for the home health team. Assess individual and family health needs, develops and supervises a plan of care, performs skilled nursing duties and tasks, teaches health management concepts and consults with staff on appropriate resources within the organization and community. Ensures that the Home Health Conditions of Participation are being met through chart reviews, IDG meetings and collaboration with HH Clinical Staff.
1. Processes HH patient calls, documents the call and notifies clinician of any issues.
2. Follow up on lab results, physician appointments and other encounters from EPIC, checks for physician notes and in-baskets physicians to request orders or issues identified by clinicians.
3. Updates the HH certification and Plan of Care (POC) when new orders are written and processed in the EMR and ensures that it is faxed to the physician and each identified patient representative in the time-frame identified.
4. Attends weekly interdisciplinary team meeting.
5. Integrates all orders from all physicians involved in the POC to ensure the coordination of all services and interventions provided to the patient.
6. Processes workflow timely in Homecare EMR.
7. Provide nursing visits for urgent patient needs and Resumption of Care as needed.
8. Assure communication with all physicians, identified care team members and the patient regarding the POC.
9. Integrate services to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care of care provided by all disciplines.
10. Assist with coordinating care delivery to meet the patient's needs, involving the patient, representative and caregiver in the coordination of care activities.
11. Ensure each patient, and his/her caregivers receive ongoing education and training provided by the agency as appropriate regarding the care and services identified in the POC. Provides training to ensure timely discharge.
12. Assists field clinicians with transitions of care, creating a proactive (fluid) care plan, monitoring and follow up, linking patient to community resources and working to align resources with patient and population needs.
13. Will communicate with care team and physician about progress towards goals and anticipated discharge.
14. Other duties as assigned.
Demonstrate Standards of Behavior and adhere to the Code of Conduct in all aspects of job performance at all times.
· Registered Nurse with recent Homecare experience, OASIS experience.
· Current licensure in the state of Washington (RCW 18.88).