When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives.
The registered nurse plans, organizes and directs home care services and is experienced in nursing, with emphasis on community health education/experience. The professional nurse builds from the resources of the community to plan and direct services to meet the needs of individuals and families within their homes and communities in accordance with home care regulations, hospital regulations and payer guidelines. The registered nurse is also trained in caring for Acute Hospital Care at Home patients, delivering care in the patient’s home, in partnership with the Command Center multidisciplinary clinical team.Job Description:
Essential Duties & Responsibilities including but not limited to:
Patient Care
1. Assumes responsibility to coordinate patient care for the temporarily assigned caseload including but not limited to: appropriate delegation to LPN staff, patient condition change visits, and completion of OASIS time points. Accepts accountability for patient satisfaction scores and quality of care outcome measure results.
2. Completes and documents an initial assessment of patient and family to determine home care needs. Provides a complete physical assessment and history of current and previous illness(es).Develops a patient specific plan of care, which establishes goals based on nursing diagnosis and incorporates therapeutic, preventive, and rehabilitative nursing actions. Includes the patient and the family in the planning process.
3. Initiates the plan of care and makes necessary revisions as patient status and needs change.
4. Initiates appropriate preventive and rehabilitative nursing procedures. Administers medications and treatments as prescribed by the physician.
5. Counsels the patient and family in meeting nursing and related needs.
6. Respects and supports patient and family’s cultural beliefs and values, individual needs, health goals and treatment preferences.
7. Provides health care instructions to the patient as appropriate per assessment and plan of care.
8. Instructs, supervises and evaluates home health aide care provided every two (2) weeks.
9. Helps manage episode of care or coordination of care with the primary disciplines in accordance with evolving occupational therapy needs and continued eligibility for services.
10. Identifies discharge planning needs as part of the care plan development and implements prior to discharge of the patient.
Communication
1. Communicates with the physician regarding the patient’s needs and reports any changes in the patient’s condition; obtains/receives physician’s orders as required.
2. Attends regular case conferences and team meetings per Clinical Manager and as needed.
3. Communicates with team LPN when delegating appropriate visits.
4. Communicates with other disciplines on the care team and community providers to coordinate the care plan (i.e. Insurance case managers, high risk case managers, elder services, protective service, etc).
5. Practices confidentiality principles set by the agency and federal HIPAA guidelines.
Documentation
1. Demonstrates proficiency in OASIS completion
2. Clinical visit notes explain the need for the skilled nursing service in light of the patient’s overall medical condition and experiences; the complexity of the services performed and the plan for the next visit based on the rationale of prior results.
3. Completes documentation in accordance with agency timeliness policies.
Hospital at Home Responsibilities:
Essential Duties & Responsibilities including but not limited to:
Clinical Roles and Responsibilities:
· Maintain clinical practice in accordance with hospital regulations regarding assessment, care coordination, treatment interventions and documentation for diverse patient populations fitting the Acute Hospital Care at Home model.
o Participate and complete Mandatory Education related to inpatient clinical care pertinent to Acute Hospital Care at Home patients as assigned by leadership.
· Admit patients transferred to Hospital at Home in accordance to Hospital at Home guidelines; complete admission documentation in Epic (electronic medical record) in accordance with Hospital policies.
Professional Development
1. Maintains and updates clinical knowledge and skills based on current nursing practice.
2. Adheres to departmental requirements for required training.
3. Identifies specific learning needs and goals and collaborates with nursing leadership in developing a plan to meet them.
Additional Duties 1. Participates in the weekend/holiday/on-call rotation as defined by BILH at Home and Hospital at Home expectations. 2. Ensures that arrangements for equipment and other necessary items and services are available. 3. Participates in in-service programs and supervises, teaches and precepts other nursing personnel per Clinical Manager.
Organizational Requirements:
· Maintain strict adherence to the Continuing Care Confidentiality policy. · Incorporate Continuing Care Standards of Behavior and Guiding Principles into daily activities. · Comply with all Continuing Care Policies. · Comply with behavioral expectations of the Continuing Care Division. · Maintain courteous and effective interactions with colleagues and patients. · Demonstrate an understanding of the job description, performance expectations, and competency assessment. · Demonstrate a commitment toward meeting and exceeding the needs of our customers and consistently adheres to Customer Service standards. · Participate in departmental and/or interdepartmental quality improvement activities. · Participate in and successfully completes Mandatory Education. · Ensure compliance with reporting requirements for any safety event including sentinel events and serious incidents. · Participate in quality and safety investigations and root cause analysis when necessary. · Take appropriate action to ensure patient safety as a result of any investigation. · Serve as a resource in quality improvement processes and techniques. · Perform all other duties as needed or directed to meet the needs of the department.
Minimum Qualifications:
Education: · Registered Nurse from a Graduate of National League for Nursing accredited school of nursing. · BSN strongly preferred.
Licensure, Certification
& Registration: · Registered nurse with current licensure to practice professional nursing in the state of Massachusetts. · Has an active American Health Association BLS. . No other forms of BLS will be accepted.
Experience: · Minimum of 2-3 years nursing experience, at least one of which is in the area of home care nursing with OASIS experience is preferred.
Skills, Knowledge & Abilities: · Demonstrates excellent observation and problem solving/critical thinking skills. · Well-developed verbal and written communication skills; essential computer skills to work with EMR. · Must be a licensed driver with an automobile that is insured in accordance with state or organization requirements and is in good working order. · Self-directed and able to work with minimal supervision; seeks support in a timely manner whenever needed. · Shows strong ability to organize and prioritize workload independently; nursing skills per competency checklist. a. Skills required (not limited to this list, but for example): physical exam, phlebotomy, intravenous access, intravenous medication infusion pump management, port access and de-access, drain management, wound care. · Exhibits flexibility in managing Hospital at Home patient assignment when applicable prioritizing acuity and iterating in partnership with Command Center clinical team when needed. · Strong skills in working within multidisciplinary team
Key Relationships:
Title Nature of Relationship To Position
1 All other clinical positions Work collaboratively in a multi-disciplinary team for quality patient outcome.
2 Clinical Manager Reports to – case conferences with on a weekly basis
3 Office Support Staff Work collaboratively to ensure accurate scheduling of pts visits, accurate insurance billing for services provided to pts
Scope/Impact Statement:
Work Schedule: Indicate either Yes or No as appropriate. Hours of work may be subject to change based upon the needs of the business/department.
On Call: YES Shift Rotation: YES Weekends: YES
Physical Requirements & Environment:
For each category, select ONE option from choices below by placing an X in the space to the left of the entry.
Mental and Visual Attention
a) The position requires basic mental and visual attention much or all of the time
b) The position requires periods of concentrated mental and visual attention.
c) X The position requires a high degree of mental and visual concentration.
Physical Exertion
Weight
d) Nature of work requires lifting or moving light weight (up to 20 pounds).
e) X Nature of work requires lifting or moving medium weight (over 20 and up to 75 pounds).
f) Nature of work requires lifting or moving heavy weight (over 75 pounds).
Dexterity
g) Flow of work and nature of duties require average manual coordination.
h) Flow of work and nature of duties require above average manual coordination.
i) X Flow of work and nature of duties require high manual co
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