Registered Nurse Hospice and Palliative Nurse
Company: Denver Work
Location: Colorado Springs
Posted on: January 15, 2022
The Home Health Primary Nurse is a professional nurse who
coordinates and directs the home care patient's care based on
individual patient needs. The Primary Nurse is responsible for the
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 are consistently
applied to new patient populations.
The Home Health Primary Nurse 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. S/he educates patients, families, caregivers, and
community providers to safely perform care. S/he provides follow-up
by evaluating the effectiveness of the home care plan, and
monitoring patient/family's response to the plan. Each Home Health
Primary Nurse belongs to a geographically organized work team.
The Home Health Primary Nurse also identifies performance
improvement and home health standard of care initiatives, and
assists to design or implement programs to address needed changes.
The Home Health Primary Nurse 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 Nurse
The Home Health Primary Nurse performs his/her job demonstrating
technical ability, understanding of job expectations, and
compliance with organizational policies and procedures. The
incumbent performs the following job responsibilities: Provides
comprehensive assessment, planning, implementation, and evaluation
for a caseload of home care clients as the primary nurse. -
A. Assessment 1. Assesses physical, functional, psychosocial, and
cognitive status of the home care patient utilizing interview
observations and physical exam techniques.
2. Assesses the home environment for safety, infection control, and
community resource needs.
3. Collects information for assessment with the patient, family,
physician, and other health care team members.
4. Incorporates multidisciplinary data into the nursing assessment
of the home care patient.
5. 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.
6. Assesses for the presence of advanced directives and facilitates
further action in obtaining information about or implementing
advanced directives if indicated.
B. Planning 1. Plans with the patient, family, and physician for
care that is feasible within the physical, financial, and emotional
resources of the family.
2. Establishes individualized, measurable goals in consultation
with the patient, family, and other health care providers.
3. Anticipates home care needs and seeks a wide range of community
resources to facilitate problem-solving.
4. Develops standards of care for patients in the home setting.
5. Utilizes home care standards and regulatory guidelines in
developing an individualized care plan with each patient and
6. Maintains a working knowledge of community resources and refers
patients and families appropriately.
C. Implementation 1. Provides skilled nursing care, preventative
rehabilitative procedures, and prescribed treatments with a variety
of patient populations within various potentially complex home
2. Maintains technical skills according to agency standards, as
measured by competency assessments during orientation and
3. Implements safe, competent care with home care patients and
families within the Home Health Agency's policies, procedures, and
standards of care.
4. Accurately follows established infection control and safety
policies and procedures.
5. Directs the use of equipment and supplies in an efficient and
6. Coordinates and directs the care of a caseload of home
7. Sets priorities of home care caseload adapting to the changing
needs of the home care patients and families.
8. Utilizes resources to problem solve new or unfamiliar patient
9. Works collaboratively with multiple community resources to best
meet the needs of the home care patient and family. Documents
components of the nursing process to reflect a comprehensive and
integrated approach to nursing care.
10. Recognizes potential problems and sets priorities according to
change in the home care patient's condition.
11. In response to information indicating urgent and/or emergent
risk to home care patients, notify the physician immediately and
notify the supervisor of the action taken.
12. Serves as a role model and resource to other nurses regarding
the care with patients and families at home.
D. Evaluation 1. Evaluate patients' responses to care based on a
continuous assessment and analysis of nursing intervention and
alternatives for nursing care.
2. Initiates change in the care plan based on this evaluation.
3. Informs the physician, nurse manager, and other appropriate
members of the health care team of changes in the patient's
condition and needs.
4. Facilitates and coordinates interdisciplinary care conferences
with groups of complex patients.
5. Exhibits sound nursing judgment and decision-making skills in
coordinating patient care.
E. Patient, family, and caregiver education: 1. Identifies and
adapts teaching materials with home care patients and families.
Creatively uses these tools to maximize the learner's success.
2. Involves the home care patient and family in the identification
of individual requirements/perceptions of learning needs.
3. Continually assesses patient/family level of understanding and
adjusts teaching and plan of care accordingly.
4. 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.
5. 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
6. Maintains a complete record of the care that is given to the
patient. Documents in the clinical record per home health agency
policy and procedure.
7. 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 care coordination, care
plan updates, addressing progress toward goals, and verbal
8. Accurately completes admission and revisit documentation,
documentation of completed communications, billing and employee
statistical information, and payroll documentation.
9. Documents regular contacts with payers.
10. Documents patient, family, and caregiver teaching. The Home
Health Primary Nurse must demonstrate professionalism and
10. Demonstrates accountability for own practice.
11. Assists in creating a positive climate conducive to
12. Works directly with new employees to see that planned
orientation to caring for home care patients is carried out.
13. Acts as a resource person on clinical problems for other
personnel caring with home care patients.
14. Acts as a role model for professional nursing and allied health
students, accompanying them on home visits as assigned.
15. Fosters the professional development of self, clinicians, and
other home health staff.
16. Evaluate your own performance in relation to home care
17. Evaluate the performance of peers as appropriate, in relation
to home care standards of practice. -
Keywords: Denver Work, Colorado Springs , Registered Nurse Hospice and Palliative Nurse, Healthcare , Colorado Springs, Colorado
Didn't find what you're looking for? Search again!