Registered Nurse, Home Care
Coordinates and provides high quality multidisciplinary health services for patients in the Region/Program consistent with Agency philosophy, policy, goals and objectives, and Standards of Nursing Practice. Works under moderate supervision.
Responsibilities: Manage 5-7 patients daily.
Assesses the physical, social and psychological needs and living conditions of the patient through professional knowledge and skills of observation, interviewing and physical examination. Travels to patientsí homes and/or other facilities with varying environments (e.g., elevated buildings, walk-ups, care facilities, single/multiple family homes, presence of pets, etc.) using approved transportation options to deliver direct care to the patient.
Acts as the coordinator of care for the multidisciplinary team by providing care to patients collaborating/making/confirming referrals to other disciplines /community agencies and ordering supplies/services and ensuring they are delivered as needed. Consults patientís MD and follows-up on problematic situations affecting care such as abnormal clinical findings or medication discrepancies. Establishes/implements/revises a plan of care with input from appropriate multidisciplinary health team members (i.e., physician, OT, PT, SW, SLP, family members) based on goals mutually acceptable to the patient and significant others. Implements the care plan by ongoing assessment, planning, coordination, counseling, teaching and supervision. Oversees/supervises the care being provided to the patient by Licensed Practical Nurses and paraprofessionals through regular home visits (every two weeks or sooner), which are in compliance with regulatory requirements. Assesses the patientís condition and updates the plan of treatment, as needed. Provides nursing care in accordance with Agency policies, practices, procedures and Standards of Nursing Practice, which may require standing, stooping, sitting, crouching, bending and stretching to deliver patient care. Documents content and process of all services provided in accordance with government regulations/requirements, Agency policies, practices, and procedures. Monitors the effect of the care plans on the patient/family health status and informs physician and other team members of changes in the client's needs.