RN/BSN Case Manager, Field Nurse
Position Summary: Under the general supervision of the Clinical Nurse Supervisor, the Home Health Registered Nurse is responsible for providing quality home health services to clients referred to the agency. Through competent application of the nursing process and use of accepted best nursing practices, the RN provides and directs the provision of home health nursing care based n agency policies and proceures and state and federal mandates for a Medicare certified home health program.
Reports To: Clinical Nurse Supervisor
Supervises: Home Care Aides and /or Homemakers, Licensed Practical nurses as assigned
Essential Duties And Responsibilities:
1. Make the initial evaluation visit o the patient and provides those services requiring substantial and specialized nursing skill in accordance with the plan of care, signed by the physician.
2. Demonstrates competency in all skills required for the agency including but not limited to venipunctures, infusion therapy, infusion therapy device care, wound care and aseptic technique.
3. Evaluates and regularly re-evaluates the nursing needs of the patient; initiates, develops, implements and makes necessary revisions to the patient's plan of care. Assesses the patient's continual care needs. Addresses all problems identified in the comprehensive assessment in the plan of care or provides evidence of the rationale for not doing so.
4. Initiates diagnostic, preventativeand rehabilitative nursing procedures as appropriate to the patient or documents rational for not doing so.
5. Observes signs and symptoms and reports changes in the patient's condition to the physician and/or other appropriate healt professionalsas often as needed.
6. Teaches, supervises and councels patients and family regarding home health nursing procedures and other care needs as appropriate to the patient's conditions. Utilizes educational material as appropriate.
7. Coordinats the plan of care and maintains continuity of patient care by acting as liaison with other health professionals assigned to the same patient.
8. Delegates tasks for which she or he believes the other health care worker has the knowledge and skill to perform, taking into consideration training, cultural competence, experience and agency policies and procedures.
9. Participates in all aspects of care, including an ongoing multidisciplinary evaluation and development of the care plan. Initiates patients care conferences for complex and/or multidisciplinary patients whenever needed or helpful to ensure good coordination of care.
10. Supervises and teaches home health aide and Licensed Practical Nurse per policies: assesses patients' need for unskilled care and revises plan of care as appropriate. Communicates plan of care changes to aide, LPN and scheduler as necessary.
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