To ensure coordination of care and services provided to all patients receiving home care services in the Home Health, Hospice, and Palliative Care Programs. Key functions are to develop a coordinated admission plan of care for patients referred; facilitate coordination of disciplines and services; use problem-solving and critical thinking skills to facilitate, coordinate, and execute effective, timely responses to clinical problems as they arise for patients; and facilitate transitions across the continuum of healthcare settings for all home care patients.
- Receives and evaluates appropriateness of the home health, hospice, and palliative care referral in collaboration with other team members (care team members, supervisor, scheduler, discharge coordinators, long-term care team, expanded care, physicians, clinic social workers, and others as needed).
- Ensures timely admission based on assessment.
- Assess clinical implications of services ordered, patient/caregiver ability to manage self-care, requirements for clinical monitoring, patient stability, patient behavior that could impact a safe plan of care, and other factors that could impact safety and efficacy of admission care plan.
- Coordinate appropriate services and interventions by obtaining appropriate initial physician orders (e.g. wound care; wound VAC, medications, etc).
- Participate in the development and coordination of a comprehensive admission plan of care that incorporates an understanding of patient-specific benefits and eligibility requirements in collaboration with care team, outpatient resources, and referring physician.
- Assure that appropriate supplies and equipment needed to provide initial services are available (e.g. wound supplies, wound VAC, DME, enteral pumps, glucometers, medications, etc) to meet patient needs.
- Make recommendations to modify the plan of care to expedite a safe transition of care, reduce risks, and enhance patient outcomes.
- Identify and communicate start of service to patient/caregiver and home care scheduling staff based on physician orders and patient care needs.
- Discusses and collaborates with referral source, home care team members, physician, discharge coordinator, and supervisor regarding complex discharges, unsafe discharge plans, and inappropriate referrals. Assists in identifying and coordinating alternative options to current care needs, which may include on-site or telephone conference with healthcare team members and patient/family/caregivers
- Advocate for the patient and family, as well as the healthcare system to optimize utilization of resources. This includes acting on behalf of the member to ensure they are informed of their financial obligations and understand their appeal rights.
- Coordinates referrals out to contract and non-contract providers for members that require home care services that can not be provided by agency staff within the Portland/Vancouver service area.
- Develop and maintain expert level of knowledge and skills related to agency policy, state practice acts, applicable state and federal regulations, utilization management, and qualifications for home care services.
- Telephone Advice/Problem-solving for patients/caregivers
- Follow up to after hours advice calls
- Resource, support, and advice for home care staff
- Physician communication and support
- Facilitates scheduling of follow up visits and procedures related to advice calls
- Oversees the day to day staffing and patient schedules and problem-solves staffing challenges to meet patient needs, within staffing rules
- Supply and DME ordering
- Assistance with paneling patients with physicians
- Facilitates Care Conferences (Case Conferences, IDT, Complex Discharges, etc)
- Coordinates care with Home Phlebotomy
- Conducts Medication Reconciliation for Therapy only cases.
- Reviews and approves Home Health Aide Care Plans for Therapy only cases.
- One year experience as a registered nurse in the acute care setting preferably medical/surgical and/or critical care nursing.
- Two years home health and/or Hospice experience.
- One year leadership experience or commensurate experience.
- BSN preferred. Will consider RN with documented three years recent experience in Community Health, Home Health, Hospice or Palliative Care in lieu of degree.
- Licensed in Oregon and Washington as a Registered Nurse. Requires license in both states prior to first day of employment.
- Valid driver's license.
- Basic Life Support CPR card for Health Care Provider. Valid card must be obtained prior to patient contact and within two weeks of hire.
- Note: This position requires a reliable automobile to travel to and from patient homes.
- Demonstrated ability to collaborate with physicians, ancillary providers, nurses, and patients to plan for transition of care to and from the home setting.
- Triage/phone experience.
- Able to perform complete physical, psychosocial, spiritual assessments.
- Able to operate stethoscope and sphygmomanometer.
- Keyboarding or typing skills.
- Able to operate a computer to perform clinical documentation.
- Highly effective problem-solving, written and verbal communication, organizational, and time management skills.
- Knowledge of Medicare, The Joint Commission, and State requirements and regulations for home care programs.
- Knowledge of Kaiser Permanente systems.
- Note: This position requires completion of a typing test.
- Four years experience as a registered nurse in the acute care preferably medical/surgical and/or critical care nursing and at least one your working in a Kaiser Permanente Home Care Program (Home Health, Hospice, or Palliative Care).
- Experience with care coordination or case management.
- Demonstrated customer-focused service skills.
- Familiarity with the use of computers and competence in keyboarding skills.
- Thorough working knowledge of Medicare regulations for home care.
- OASIS-C Certification
- Certified Hospice and Palliative Care Nurse
- Rehabilitation Nursing
- Hospice care and the dying process.
- Utilization management, discharge planning, care coordination, and case management.
$34.10 - $48.32
Kaiser Permanente - 12 months ago
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