RN Case Manager - Home Health

Description

Description

Adoray Home Health and Hospice is recruiting for a full-time Home Health Registered Nurse.

POSITION SUMMARY

The Registered Nurse acts as a case manager for assigned case load. She/he is responsible for providing skilled nursing care and teaching to patients and their families in their place of residence. The nurse is responsible for ensuring the physician's orders are carried out on a timely basis. The nurse completes all necessary documentation and participates in other activities as assigned.

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Makes initial assessment visit to patient to determine appropriateness for home health services. Questions when an admission may not be appropriate by contacting supervisor for direction.
• Determines need for other disciplines (aide, PT, OT, SpT, SW) or services, and obtains order and notifies office staff.
• Determines frequency of visits for patients and receives minimal recommendations for changes from supervisor when reviewed.
• Assesses for and implements disease-specific care paths as Adoray’s home health procedures require.
• Develops and updates realistic, measurable patient goals with patient and/or caregiver.
• Conducts ongoing planning and assessment activities based on patient’s condition.
• Implements home health plan of care as outlined on the 485.
• Follows established home health care pathways as indicated.
• Performs medication reconciliation at the SOC, ROC, recertification and any other time there are multiple changes in medications.
• Demonstrates effort is put forth in ensuring patient hospitalizations are avoided by exhibiting exemplary nursing judgment and by doing such things as: making extra nursing visit(s) as warranted; contacting MD of any significant changes and ensures there is follow-up with the MD when there is no response; following up with the patient and/or caregiver timely by phone or visit when there is initiation of a treatment or medication change, etc.
• Exhibits sound nursing judgment which positively affects individual patient outcomes, as evidenced by quality improvement reports.
• Implements new physician orders timely and accurately.
• Assesses for and provides patient and family teaching related to patient’s
• health situation on an ongoing basis (i.e., medications, disease processes, treatments, etc.) and provides written teaching information as appropriate.
• Serves as case manager, as assigned, following established policies.
• Contacts all other disciplines involved in home health patient’s care with update within 48 hours of admission (or sooner if patient’s condition warrants it) as well as ongoing.
• Ensures there is appropriate follow-up with MD if there are discrepancies with medications or treatment protocols.
• Updates the MD with changes in home health patient’s condition, including such things as patient blood level results; vital signs or weights that are outside established parameters; compliance issues; etc.
• Ensures supervisor or clinician covering the office is notified if call is placed to physician with update, in case there are call-backs and office staff follow-up is necessary.
• Updates supervisor on regular basis regarding status of patients, including a consultation prior to any discharges.
• When case managing, assures that all caregivers receive necessary information for appropriate patient care, coordinating with them regularly, as outlined in agency policies.
• Provides thorough communications to other team members and coverage staff to ensure continuity of patient care.
• Thoroughly documents comprehensive assessment for home health admits.
• Documents towards patient goals based on home health POC at each visit.
• Completes required home health recertification paperwork within allotted 5 day window.
• Supervises home health aide at least every two weeks and documents supervision.
• Documents coordination of care of assigned case load with all other disciplines involved in patient’s care weekly.
• Develops accurate and individualized 485 POC within 48 hours of admission.
• Ensures medication profile is complete (i.e., “new” vs. “changed”, start and stop dates, all coumadin doses, IV meds, reason for prn meds, etc.) and consistent with physician’s orders.
• Documents all medication reconciliation activities.
• Thoroughly documents teaching provided to patient and/or caregivers (including paid help).
• Documents all coordination activities with caregivers (including paid help).
• Ensures any wound care, edema, IV, pain, etc. assessments are completed thoroughly and accurately per agency policy.
• Documents evidence of updates to physician for home health patients whenever there is a change in status.
• Ensures all home health documentation to be included in the medical record (except 485 as noted) is turned in within 72 hours of visit.
• Ensures all documentation included in the home health medical record is thorough, complete and accurate.
• Turns MD verbal orders into office within 24 hours of receipt for processing and mailing.
• Completes medical supply worksheets timely and accurately.
• Completes payroll paperwork timely and accurately.
• Keeps visit schedule in EMR current.

Requirements

Requirements

Minimum Qualifications

• BSN or minimum of two years of home care experienced preferred.
• Minimum of two years of clinical experience.
• Current Wisconsin license required.
• Current driver's license.

Knowledge, Skills and Abilities

• High level of attention to detail
• Ability to work autonomously and make independent judgments.
• Ability to manage conflicting priorities and handle multiple tasks/projects concurrently
• Ability to work well as part of a team and independently
• Exhibit excellent written and verbal communication and organizational skills
• Exceptional customer service skills
• Display and promote high standards of ethical conduct and behaviors consistent with organizational standards