Job Summary: The RN Coordinator of Care assesses, plans and coordinates home care services for assigned patient caseload and provides skilled nursing care in accordance with professional standards, regulatory guidelines, accreditation standards and Agency policies.
1.Admits patients to the agency in accordance with agency admissions policy and regulatory requirements.
2.Establishes and provides a plan of treatment for the patient based on results of the evaluation visit, patient needs and physician orders.
3.Involves the patient and appropriate others in the planning, implementation and assessment of the intervention/treatment program.
4.Completes the Oasis Start of Care Assessment and obtains appropriate admission consents as per agency policy and regulatory requirements.
5.Submits all admission paperwork within 24 hours of the initial visit.
6.Provides an initial verbal report to the Clinical Manager within 24 hours of the initial visit.
7.Demonstrates understanding of cultural issues and conducts visits in a culturally sensitive manner.
8.Provides education to patient/family and paraprofessional staff on the plan of care, disease process, medications, universal precautions, infection control, nutrition, safety emergency measures, patients care and community resources.
9.Provides written instructions and educational materials to the patient as indicated.
10.Instructs, supervises, and evaluates Home Health Aides on initial start of care, and every fourteen days and/or as needed.
11.Meets with the Clinical Manager every two weeks and as need for case conferences to discuss changes in patient condition, changes in treatment/medications, progress towards goals and response to treatment.
12.Conducts the interdisciplinary case coordination with the team every two weeks and/or as needed to discuss changes in the patient’s status, care plan changes, ongoing care needs, long-term care planning and plans for discharge.
13.Documents all coordination of care activities into the patient’s electronic clinical record to include the name of professionals communications took place with, issues and plans that were discussed and the results of the coordination efforts.
14.Documents on an ongoing basis, patient services provided, and responses to services/treatment, changes in status relative to the plan of care and achievement of goals.
15.Submits all documents within 24-48 hours of visit.
16.Submits tentative weekly itinerary by Thursday of previous week.
17.Performs other duties as assigned or requested.
Knowledge, Skills And Requirements
QUALIFICATIONS: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
EDUCATION AND/OR EXPERIENCE: Graduate of an accredited school of nursing; Bachelor’s degree (B.A.) in Nursing from a four-year college or university preferred.
CERTIFICATES, LICENSES, REGISTRATIONS: Current License and Registration to practice as a Nurse in NYS; Infection Control Certificate. PRI screen certification and SAMM assessment skills preferred.
LANGUAGE SKILLS: Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure manual. Ability to effectively present information and respond to questions from groups of managers, clients, and the general public.
REASONING ABILITY: Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.
OTHER QUALIFICATIONS: Must be able to travel locally by public or private transportation to make home visits. Valid driver’s license, car registration and insurance as applicable
OTHER SKILLS AND ABILITIES: Knowledge of current principles, practices and objectives of community health nursing; skills applicable in an HIV-specific certified home health agency preferred. Able to perform data entry. Must be computer literate with basic skills in Microsoft Word and Excel. Knowledge of computer databases desirable.