Achieve the physical, mental and social well being of the client within Agency policy. Supports utilization of medical resources through application of clinical expertise. Monitors clinical, functional and financial outcomes. Assumes responsibility for the ongoing interdisciplinary assessment and development of the individualized plan of care in partnership with the patient, representative (if any) and caregiver. Communicates with the physician who is responsible for the home health plan of care and other health care practitioners as appropriate related to the current home health plan of care.
Responsibilities:
1. Assessment of physical, emotional, socio-economic needs and environmental needs of patients and their families.
2. Provides services that are ordered by the physician as indicated in the plan of care. Communicates with all physicians involved in the plan of care and other health care practitioners as appropriate.
3. Develops, implements and evaluates the plan of care in partnership with the patient, representative (if any), caregiver and physician(s).
4. Coordinates services with the patient, family and others involved in the care plan. Provides patient, caregiver, family counseling and education.
5. Regular evaluation of patient progress, prompt action when change in patient's condition is noted or reported, and termination of care when goals of management are attained, or when termination of case is required according to Agency policy.
6. Participates in the agency quality assurance and performance improvement prora, and the agency-sponsored inserice training.
7. Identification of patient and family needs for other home health services and referral for same, when appropriate when appropriate.
8. Responsibility for supervisor of the services rendered to the patient and family by the homemaker/home health aide, according to State and Federal guidelines and Joint Commission standards, and submission of periodic evaluation of such to the Home Health Aide Supervisor.
9. Fulfills all compliance responsibilities related to the position including preparing clinical notes and attending in-sevrice training.
10. Performs other duties as assigned.
Education Skills Experience:
Required: RN diploma with over 3 years job related experience will be considered in lieu of Associates Degree. Requires strong research skills, clear and concise interpersonal communication skills. Knowledge of systems integration.Minimum Experience: one yearDesired: Bachelor's Degree in Nursing; Experienced in qualified home health agency.
Other Information:
Required: RN diploma with over 3 years job related experience will be considered in lieu of Associates Degree. Requires strong research skills, clear and concise interpersonal communication skills. Knowledge of systems integration.Minimum Experience: one yearDesired: Bachelor's Degree in Nursing; Experienced in qualified home health agency.