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Registered Nurse Hospice and Palliative Nurse

Company: Denver Work
Location: Colorado Springs
Posted on: January 15, 2022

Job Description:

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 Manager.
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. -
Essential Functions:
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 family.
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 situations.
2. Maintains technical skills according to agency standards, as measured by competency assessments during orientation and annually.
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 cost-effective manner.
6. Coordinates and directs the care of a caseload of home patients.
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 situations.
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 verbal.
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 orders.
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 leadership.
10. Demonstrates accountability for own practice.
11. Assists in creating a positive climate conducive to learning.
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 standards.
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

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