Under the direct supervision of the Admissions Supervisor, this position is responsible for the development and timely submittal of the Level of Care (LOC) tool to the organizational shared drive and conducting initial In-Home Assessments (IHA) as part of the IHA Team. When needed or requested, the role involves implementing homecare services for program participants, including the coordination of all Durable Medical Equipment.
Essential Functions
Assess, using the nursing process, the home care needs of a frail elderly population, and identify and develop an initial plan of care as needed.
Based on nursing assessment, complete and submit the LOC determination form to the supervisor for review.
Review medical records as needed to complete LOC. If medical records can't be accessed, complete LOC with other relevant information (e.g., hospital discharge information, medications).
Conduct initial Home/RN assessments at the participant's home during the team IHA.
Maintain an up-to-date active list of all LOCs submitted, including date submitted, decision, follow-up, etc.
Follow up on all deferred prospective enrollees as needed and resubmit required information to request approval.
Participate in weekly enrollment team meetings as well as interdisciplinary team meetings as needed.
Assist in the transitioning of care and monitoring hospitalizations and skilled nursing facility patients to ensure appropriate transition.
Communicate and interact with patient caregivers and/or family members as needed.
Additional Duties and Responsibilities
Follow established departmental and position-specific policies and procedures and update as needed.
Stay informed of all regulations and standards to ensure compliance with orders or directives issued by duly constituted government/regulatory agencies.
Enhance professional growth and development through participation in educational programs, current literature, in-service meetings, and workshops.
Attend meetings as required and participate on committees as directed.