Demonstrates knowledge of the nursing process as a standard, incorporating elements of holistic person-centered care through the collection, verification and organization of data about a patient’s health status, planning for care, implementation of the plan and evaluation. Provides direct patient care in the home or setting where the patient refers to as home. The RN is under the direction of the Director or designee. Performs detailed and accurate assessments utilizing a standardized assessment (OASIS) of patients and completes documentation in a timely and accurate manner according to home health policy and regulatory requirements. Facilitates patient hand-offs and provides assistance to move the patient through the care continuum. Understands the principles of case management to ensure effective coordination of care and utilization of community resources. Works collaboratively with other members of the healthcare team, co-workers, physicians, and the community emphasizing a teamwork environment. Ability to implement quality care standards for patients served. Coordinates provision of patient care for assigned patients, maintains competency levels annually and attends continuing education as applicable. Delegates appropriate tasks as needed. Works with the Director and/or clinical coordinator to assure patient visits are being provided as outlined in the plan of care.
COMMUNICATION: Demonstrates good communication skills to facilitate implementation of quality core measures, attends meetings and weekly case conferences. Maintains open communication with the interdisciplinary team. Maintains open communication with the Director and/or clinical manager/coordinator in relation to case management responsibilities or patient concerns. Utilizes appropriate chain of command to collaboratively and proactively problem solve as needed. Diffuses patient/family complaints prior to involving the Director or clinical coordinator. Attends education when offered related to competencies or changes in processes. Communicates to staff the need for compliance with CMS and other regulatory bodies to assure the provision of safe, quality care.
ADAPTABILITY: Has a “can do” attitude, keeps the department running smoothly, promotes teamwork, and a no-blaming environment while setting the tone for the department by being a good role model. Maintains a positive attitude and flexibility regarding fluctuating patient census and staffing needs. Demonstrates critical thinking skills and actively completes assignments, documentation per agency policy. Able to prioritize and multi-task when the department gets busy. Keep calm during stressful times.
Aptitudes: Ability to achieve cognitive, organization and emotional maturity to deal respectfully and effectively with multiple tasks, stresses, deadlines, difficult situations and/or customers. Possesses positive interpersonal and communication skills necessary for effective, non-judgmental, and empathetic patient care and customer relations. Positive attitude with emphasis on customer satisfaction and exceptional patient care. Ability to achieve expected organizational behavioral standards. Open to feedback and a quickly changing environment, which requires flexibility in scheduling, equipment, and department assignments. Strives to put the patient first above personal needs and beliefs. Acts as a mentor to less experienced staff and maintains a positive attitude.
KNOWLEDGE/EXPERIENCE: At least 2 years of Acute Care, Home Health nursing, or other relevant nursing experience required. Sufficient knowledge, critical thinking skills, and experience to demonstrate ability to work autonomously. Must demonstrate knowledge about CMS and other regulatory bodies pertaining to the department. Leadership knowledge and ability to direct staff, assess their competency levels, and delegate appropriate tasks, as required by the Board of Nursing “Rules for Delegation”.
EDUCATION: Graduate of accredited professional school of nursing.
LICENSE/CERTIFICATION/REGISTRY: Current Montana License as a Registered Nurse, BLS. Additional certifications as required.
Conducts start of care, resumption of care, transfers and discharges in a timely manner according to regulatory guidelines. Serves as a team resource and assists staff members as available with difficult patient situations. Proficient competency level to perform blood draws, PICC line management, wound care and other skills as ordered or required. Understand the principles of patient education and health literacy to promote patient self-management skills. Regularly attends staff meetings and educational programs as applicable or mandated. Effectively manages time and resources responsibility. Collaborates with the interdisciplinary team in providing quality care to home care patients. Ability to take call and work weekends and holidays on a rotating schedule. Provides comprehensive case management to a group of assigned patients. Effectively works with the clinical manager/coordinator.