The primary function of the TeleHealth High Risk Nurse, RN is to act as a primary visiting nurse/case manager for a group of patients having a variety of chronic care diagnoses and nursing care needs and designated as a patient in the TeleHealth Management program. The position has primary responsibility for managing the patients’ resources and outcomes; demonstrates a high degree of independent critical thinking in the initial evaluation/admission, evaluation and set-up for telehealth, care planning, case management/resource management, telehealth monitoring, coordination & communication with Outcomes Managers, MD and other service providers.
MINIMUM JOB REQUIREMENTS
Education & Qualifications:
• Education: Graduate of an accredited Diploma, Associate Degree or Baccalaureate School of Nursing. Preference is given to individuals with Baccalaureate Degree.
• Previous Experience: Two+ years nursing experience in Home Health strongly preferred. If less than 2 years home health experience, must also have at least one to two years practicing nursing in the acute care hospital setting. Clinical case management in any health care setting desirable.
• Licensure/Certifications: Registered Nurse License through the GA Board of Nursing; CPR certified required; Valid Georgia Drivers License and auto insurance
• Knowledge/Training: Clinical experience must reflect strong assessment and triage skills, customer service and communication skills and critical thinking.
• Computer Skills: Must be familiar with general use and functions of the computer, such as, user names and password concepts; internet; e-mail; navigation of computer desktop or laptop, including starting programs, using files, and windows, effectively use navigation buttons and tool bars; ability to self-manage online HR services and online training programs.
• Transportation: Must have reliable transportation
Job Specific Expectations:
• Conducts comprehensive assessment at admission and all subsequent time point assessments.
• Evaluates for telehealth monitoring needs or other self-monitoring activities; evaluates for other service needs and refers appropriately.
• Assesses for therapy needs for an exercise program and/or ADL program using established criteria.
• Establishes the Plan of Care (POC) for the patient based on patient specific outcome goals; includes plan for visit schedule and telephone assessment & follow-up.
• Ensures that the POC reflects standards of care & practice for the patient’s diagnosis and care needs.
• Uses standard HH approved materials for patient education and self management.
• Promotes realistic & achievable patient self-care management of chronic disease processes.
• Determines a schedule for patient visits, telephone contact, re-certification and tele-monitoring which is based on outcome goals and established standards of care.
• Collaborates with family members/caregiver in POC.
• Performs all primary scheduled home visits, telemonitoring, telephone follow-up and daytime prn visits
• Uses Tele-triage assessment and tools; Collaborates with after-hour call/triage nurses to ensure continuity of learning, teaching, interventions.
• Performs daily telemonitoring (or other routine self monitoring) and uses data to manage the care of the patient and communicate with the MD and other care providers.
• Coordinates resource needs and outcome goals/achievement with the Outcomes Manager.
• Monitors/ manages to outcome goals; uses report tools established for program; communicates outcomes; evaluates own effectiveness; participates in evaluating effectiveness of disease management & continued development of program..
• Documents all activity in the clinical record with accuracy, timeliness and according to Home Health standards and guidelines.
• Participates in case review & case conferences regularly with Outcomes Manager, Resource RN, Clinical Manager and other services.
• Works collaboratively with other Team nurses toward team goals; cover visits/phone calls/ telemonitoring for each other.
• Participates in training and education of visiting staff in DM program
• Participates in the tele monitoring program-- needs assessment, training, education
• Participates in the 1) evaluation of the effectiveness of the DM program and in 2) program improvement activities.
Visiting Nurse Health System, Georgia’s largest nonprofit provider of healthcare and hospice at home, 64 year tradition of serving its mission of improving the lives of those we serve. Our vision is to set the standard for quality in Georgia and be the first place patients, families, payers and other healthcare providers select when in need of homecare or hospice services.
Each year Visiting Nurse Health System provides professional clinical and care management services to more than 25,000 patients in metropolitan Atlanta.
Visiting Nurse is an EOE.
Visiting Nurse Health System - 6 months ago
Visiting Nurse is the leading provider of home healthcare and hospice care in Atlanta, Georgia, helping patients successfully manage their...