Basic Job Function Summary
Provides professional nursing care to the organization’s patients as prescribed by the physician, and/or requested by the patient/family, and in compliance with the state’s Nurse Practice Act, any applicable licensure/certification requirements, and the organization’s policies and procedures. The Hospital at Home RN is proficient in OASIS assessments/documentation, and is fully responsible for the patient assessment, care planning development, obtaining orders, initiating tele-monitoring, and communicating to the care team. The Hospital at Home RN is able to meet all productivity standards, and is knowledgeable regarding evidence based care and payer requirements. The hospital at home nurse is capable of expanding the scope of practice in general or specialty areas of nursing. Provides functional support to Home Healthcare Aides and LPNs as needed.
Provides functional supervision of LPN’s and Hospice / Home Care Aides.
· Ensure the performance of a comprehensive assessment of the patient's physical and psychosocial condition on an ongoing basis throughout the continuum of care and determines the agency's ability to meet those needs in the home care setting.
· Accurately assesses patient at admission, at required time points, and as needed, utilizing appropriate standardized documentation, (meeting 90% OASIS accuracy where applicable).
· Demonstrate knowledge and skills necessary to provide care appropriate to the patients served within the hospital at home program. Determining patient problems, age-based needs, desired outcomes and nursing interventions based on the assessment.
· Collaborates with multi-disciplinary team and patient; to develop appropriate assessment-based plan of care including: attainable patient and episode goals, services needed to improve and/or stabilize medical condition, and promote discharge from hospital at home. Participates in timely revision of the plan of treatment as appropriate.
· Implement the patient plan of care in collaboration with the health care team, to include procedures, orders for medication and treatments as prescribed by the physician in accordance with the plan of treatment.
· Reports changes in patient condition as appropriate and in a timely manner, to the family, physician, and/or Case Manager/designee, and obtains orders for changes in the plan of treatment to respond to the patient's condition.
· Provide education as indicated after assessing the learning needs of the patient, family, staff members and students.
· Informs the patient/caregiver about the care/services available, patient obligation for payment, and other responsibilities and rights, before care is initiated.
· Makes appropriate referrals for evaluation/care to other disciplines and services, and communicates/coordinates care with others to ensure effective and efficient care.
· Initiates tele-monitoring and other technology used during the patient episode of care.
· Utilize manual and automated information systems to improve efficiency and effect productivity.
· Demonstrate a current working knowledge of equipment, instrumentation and medications.
· Utilizes and implements appropriate tools and pathways per guidelines, EMR and/or policy and procedure (e.g. education checklists, pathway protocols, Hospital at Home Program Instructions, etc.).
· Accurately documents observations, interventions and evaluations pertaining to patient care management and services in accordance with organizational policy and procedure, efficiently utilizing the point of care information system. This will include: assessments, visit reports, medication information, treatments, coordination of services, patient progress or lack of progress toward goals, and contacts with physicians and agency and community providers
· Documents in home to assure timely submission of patient data to the office for inclusion in the patient record. Syncs after every visits
· Participates in quality improvement processes including peer review and huddles as directed.
· Demonstrates self-education and responsibility for own professional growth and development as evidenced by: (a) Identifies and documents education needs. (b) Corrects the knowledge deficit through multiple learning activities. (e.g. participating in-service presentations) (c) Mentoring and role modeling, (consulting with clinical supervisor, and other clinical experts for guidance).
· Assures that standards and practices reflect current standards and best practice within area of expertise.
· Acts independently and responsibly to perform duties on a consistent basis and in a timely manner.
· Delegates tasks to appropriate personnel as indicated by skill level and professional standing (e.g. LPN, HHA)
· Participates in the orientation of new employees, preceptorship of new RNs and the educational process of nursing students as appropriate.
· Identifies with and demonstrates a commitment to the mission and values of Trinity Health.
· Provides services in a manner that supports continuous quality improvement, customer-oriented focus, and quality patient care outcomes, at or above top quartile.
· Ensures that services are provided in a manner that supports a quality work environment for employees, as measured by participation in care conferences, initiatives to strengthen clinical care.
· Able to effectively set patient/family expectations, assuring that patient care experiences and satisfaction are achieved at or above the 75th percentile.
· Maintains a current working knowledge of applicable Federal, State and local laws and regulations, the Organizational Integrity Program, Code of Ethics, as well as agency policies and procedures and adheres in a manner that reflects honest, ethical and professional behavior.
· The duties and responsibilities described are not a comprehensive list and additional tasks may be assigned from time to time, as the scope of the job may change as necessitated by business demands
· Graduate of an approved Nursing education program, BSN required, or must be actively enrolled in BSN program with completion, no later than December, 2019
· Current Registered Nurse licensure in the state of practice.
· In CA: Must have one year of professional nursing experience by regulation.
· Must have a minimum of one (1) year experience as a professional acute care nurse.
· Home healthcare experience required, with demonstrated competence, accuracy in OASIS and developing a plan of care.
· Must have current Driver’s license and reliable transportation to and from work site.
· Ability to consistently demonstrate commitment to the mission and Organizational Code of Ethics, and adhere to the Compliance Program.