Registered Nurse, Case Manager - Care at Home

Day (United States of America) Registered Nurse, Case Manager - Care at HomeThe Home Health Nurse Case Manager is a professional nurse who coordinates and directs the home care patient's care based on individual patient needs. The Nurse Case Manager is responsible for independent management of the Home Health patient population requiring the use of advanced assessment, teaching and decision-making skills. The nurse is responsible for ensuring that appropriate referrals to other services are made, interdisciplinary conferencing takes place regularly, and appropriate documentation is completed. Relevant knowledge and experience is consistently applied to new patient populations. The Nurse Case Manager cares for a caseload of home health patients by evaluating the patient for appropriateness of home health and developing the home care plan in conjunction with the physician. Nurse Case Manager educates patients, families, caregivers and community providers to safely perform care. Nurse Case Manager provides follow up by evaluating effectiveness of the home care plan, and monitoring patient/family's response to the plan. The Nurse Case Manager also identifies performance improvement and home health standard of care initiatives, and assists to design or implement programs to address needed changes. The Nurse Case Manager has knowledge of home care regulations and third party reimbursement as it impacts the delivery of services. This position will have on-call responsibilities and is under the general supervision of a Patient Care Coordinator.Job Functions/Responsibilities:AssessmentAssesses physical, functional, psychosocial, and cognitive status of the home care patient utilizing interview observations and physical exam techniques.Assesses the home environment for safety, infection control, and community resource needs. Collects information for assessment with the patient, family, physician and other health care team members. Incorporates multidisciplinary data into the nursing assessment of the home care patient. Provides ongoing nursing assessment with the patient, family and home environment to determine physiologic or psychosocial risk. Applies previous nursing experience and base of knowledge and adapts with the patient and family in a home setting.Assesses for the presence of advanced directives and facilitates further action in obtaining information about or implementing advanced directives if indicated.PlanningPlans with the patient, family and physician for care which is feasible within the physical, financial and emotional resources of the family.Establishes individualized, measurable goals in consultation with the patient, family and other health care providers.Anticipates home care needs and seeks a wide range of community resources to facilitate problem solving. Develops standards of care for patients in the home setting. Utilizes home care standards and regulatory guidelines in developing an individualized care plan with each patient and family.Maintains a working knowledge of community resources and refers patients and families appropriately.Implementation:Provides skilled nursing care, preventative rehabilitative procedures, and prescribed treatments with a variety of patient populations within various potentially complex home situations.Maintains technical skills according to agency standards, as measured by competency assessments during orientation and annually.Implements safe, competent care with home care patients and families within Halifax Health Job Description policies, procedures and standards of care.Accurately follows established infection control and safety policies and procedures. Directs the use of equipment and supplies in an efficient and cost effective manner. Coordinates and directs the care of a caseload of home patients. Sets priorities of home care caseload adapting to the changing needs of the home care patients and families. Works collaboratively with multiple community resources to best meet the needs with the home care patient and family.Documents components of the nursing process to reflect a comprehensive and integrated approach to nursing care.Recognizes potential problems and sets priorities according to change in the home care patients condition. In response to information indicating urgent and/or emergent risk to home care patients, notifies the physician immediately and notifies the supervisor of the action taken.Serves as a role model and resource to other nurses regarding the care with patients and families at home.Evaluation:Evaluates patient's responses to care based on a continuing assessment and analysis of nursing intervention and alternatives for nursing care.Initiates change in the care plan based on this evaluation. Informs the physician, nurse manager, and other appropriate members of the health care team of changes in the patient's condition and needs.Facilitates and coordinates interdisciplinary care conferences with groups of complex patients. Exhibits sound nursing judgment and decision making skills in coordinating patient care.Patient, family and caregiver education:Identifies and adapts teaching materials with home care patients and families Involves the home care patient and family in identification of individual requirements/perceptions of learning needs.Continually assesses patient/family level of understanding and adjusts teaching and plan of care accordingly. Ensures that the home care patient and family demonstrate the knowledge and abilities regarding home care rights and responsibilities, diagnosis, health care status, treatment, skills, medication regime, advance directives, and adaptive behaviors gained as a result of teaching interventions.Develops, implements and evaluates teaching programs with home care patients and families.The Home Health Primary Nurse must possess excellent communication skills, both written and verbal.Maintains a complete record for the care that is given with the patient. Documents in the clinical record per Halifax Care at Home policy and procedure.Maintains an updated clinical record on each patient at all times, meeting required deadlines for documentation of certification, re-certification, aide supervision reports, aide care plan updates, routine recording of case coordination, care plan updates, addressing progress toward goals, and verbal orders.Accurately completes admission and revisit documentation, documentation of completed communications Documents patient, family and caregiver teaching.The Nurse Case Manager must demonstrate professionalism and leadership.Demonstrates accountability for own practice. Assists in creating a positive climate conducive to learning. Works directly with new employees to see that planned orientation to caring with home care patients is carried out. Acts as a resource person on clinical problems for other personnel caring with home care patients. Fosters the professional development of self, clinicians and other home health staff. Evaluates own performance in relation to home care standards. Evaluates performance of peers as appropriate, in relation to home care standards of practice. Acts as a role model in demonstrating commitment to Halifax Care at Home. Participates in the development of program goals and evaluates progress toward goal achievement. Attends staff meetings, nurse's meetings, agency in-services, and staff development programs. Maintains Halifax Health mandatory education requirements. Participates in committees/meetings as delegated or appointed.Participates in training for and implementing specialized leadership roles as available, which may include:Competency assessment of other RNs and/or LPNs via peer review. Peer review, including certification and/or re-certification work and other documentation. Specialization in performing patient admissions to the agency. Rotates through a cycle for providing on-call coverage during hours when agency is closed. (4:30 PM 8 AM weekdays, and all day Saturdays, Sundays, and Holidays.)Scheduling coverage during on-call or according to agency need. Includes facilitating and ensuring scheduling of pt. visits by all agency services.Phone triage coverage as part of the on-call role or according to agency need. Includes being available to patients and other health professionals as a home health resource nurse.Serves as a preceptor for new home health employees. Participates as an educator in formal education programs. Maintains productivity according to agency standards at Halifax Care at Home Provides care in a geographically logical manner by reading and updating directions to home in the medical record, and using map reading skills.Uses technology effectively to support nursing practice and create efficiencies in care delivery. Must exhibit teamwork by collaborating with individuals and groups to establish and attain common goals.Contributes to and supports the effective operation of Halifax Care at Home:Identifies, documents and assists with resolving home health client, practice, and system issues. Participates in and assists in the ongoing development of Halifax Care at Home policies, procedures, standards of care and documentation systems.Demonstrates flexibility in adjusting assignments to meet the needs of the agency. Maintains an updated schedule in the office, checks schedule for changes regularly, and communicates scheduling changes to the office promptly.Maintains consistent availability throughout the workday, responding to Halifax Care at Home communications via E-mail, voice mail, phone call within expected timelines.Demonstrates leadership within the primary nurse role on a geographically organized work team, working with interdisciplinary professional and support personnel who provide care with patients, families and caregivers in the community.Demonstrates responsibility for team relationship development, team task completion, and individual caseload management. Attends team meetings regularly, and may lead the team meeting in the absence of the Nurse Manager. Effectively delegates and supervises delegated care, e.g., care provided by the home health aide and the LPN. Initiates interdisciplinary collaboration to positively impact the outcomes of health care provided to patients and their