Home Health & Hospice Weekend Coordinator

NORTHERN COUNTIES HEALTH CARE INC•Saint Johnsbury, VT

About The Position

Responsible for coordinating home care and hospice services on weekend days and managing a home care and hospice caseload on weekdays. Coordinates weekend nursing schedules, patient care and intake of referrals for home care and hospice. Plans, organizes and directs home care and hospice services and is experienced in nursing, with emphasis on community health education/experience. 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. Supervisory Responsibilities: This position has no direct supervisory responsibilities. Essential Job Functions/Responsibilities: COORDINATION 1. Communicates with the Referral Source to facilitate the process of admission of the person into the agency. 2. Obtains all necessary referral information, including, but not limited to, physician ordered medications and treatments (signed by provider) and enters information into electronic medical record. 3. Ensures patient meets eligibility requirement for certain admission types and if does not, assists referral source with exploring alternative options. 4. Communicates with the patient or family when necessary to give an accurate description of the services the patient is referred to. 5. Establishes and maintains positive working relationships with customers and referral sources and responds to customer requests and concerns. 6. Maintains comprehensive working knowledge of community resources and assists referral sources in accessing community resources should services not be provided by Northern Counties Health Care. 7. Monitors and responds to weekend tele-monitoring data. 8. Responds to calls from the answering service on Saturday and Sunday, 8am to 4pm. 9. Coordinates patient care and communicates scheduling changes to nurses. DIRECT CARE 1. Completes an initial assessment of patient and family to determine home care needs and regularly re-evaluates patient nursing needs. 2. Initiates the plan of care and makes necessary revisions as patient status and needs change. 3. Develops a care plan, 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. 4. Initiates appropriate preventive and rehabilitative nursing procedures. Administers medications and treatments as prescribed by the physician. Provides direct patient care as defined in the State Nurse Practice Act. 5. Counsels and educates the patient and family in meeting nursing and related needs. 6. Identifies discharge planning needs as part of the care plan development and implements prior to discharge of the patient. 7. Acts as Case Manager when assigned by Nurse Manager and assumes responsibility to coordinate patient care for assigned caseload. 8. Participates in care conferences and in-services. COMMUNICATION 1. Prepares clinical notes and updates the primary physician when necessary and at least every 60 days. 2. 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. 3. Communicates with community health related persons to coordinate the care plan. ADDITIONAL DUTIES 1. Participates in on-call and holiday duties. 2. Ensures that arrangements for equipment and other necessary items and services are available. 3. Instructs, supervises and evaluates home health aide care provided in accordance with state and federal regulations. The above statements are intended to be a representative summary of the major duties and responsibilities performed by incumbents of this job. The incumbents may be requested to perform job-related tasks other than those stated in this description.

Requirements

Registered nurse currently licensed in the state of Vermont.
Complies with acceptable professional standards and practice.
Excellent observation, verbal and written communication skills, problem-solving skills, basic math skills, and nursing skills per competency checklist.
Prolonged or considerable walking or standing. Able to lift, position, or transfer patients. Able to lift supplies and equipment. Considerable reaching, stooping, bending, kneeling, or crouching. Visual acuity and hearing to perform required nursing skills.
May occasionally be in a position to lift and/or carry an item weighing up to 50 pounds.
Licensed driver with an automobile that is in good working order and insured in accordance with the organization’s requirements.
Requires knowledge of potential exposure to communicable diseases and bodily fluids.
Requires working under stress in emergency situations during irregular hours.

Nice To Haves

Home Care and Hospice experience preferred.

Responsibilities

Coordinates weekend nursing schedules, patient care and intake of referrals for home care and hospice.
Plans, organizes and directs home care and hospice services
Communicates with the Referral Source to facilitate the process of admission of the person into the agency.
Obtains all necessary referral information, including, but not limited to, physician ordered medications and treatments (signed by provider) and enters information into electronic medical record.
Ensures patient meets eligibility requirement for certain admission types and if does not, assists referral source with exploring alternative options.
Communicates with the patient or family when necessary to give an accurate description of the services the patient is referred to.
Establishes and maintains positive working relationships with customers and referral sources and responds to customer requests and concerns.
Maintains comprehensive working knowledge of community resources and assists referral sources in accessing community resources should services not be provided by Northern Counties Health Care.
Monitors and responds to weekend tele-monitoring data.
Responds to calls from the answering service on Saturday and Sunday, 8am to 4pm.
Coordinates patient care and communicates scheduling changes to nurses.
Completes an initial assessment of patient and family to determine home care needs and regularly re-evaluates patient nursing needs.
Initiates the plan of care and makes necessary revisions as patient status and needs change.
Develops a care plan, which establishes goals based on nursing diagnosis and incorporates therapeutic, preventive, and rehabilitative nursing actions.
Initiates appropriate preventive and rehabilitative nursing procedures. Administers medications and treatments as prescribed by the physician. Provides direct patient care as defined in the State Nurse Practice Act.
Counsels and educates the patient and family in meeting nursing and related needs.
Identifies discharge planning needs as part of the care plan development and implements prior to discharge of the patient.
Acts as Case Manager when assigned by Nurse Manager and assumes responsibility to coordinate patient care for assigned caseload.
Participates in care conferences and in-services.
Prepares clinical notes and updates the primary physician when necessary and at least every 60 days.
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.
Communicates with community health related persons to coordinate the care plan.
Participates in on-call and holiday duties.
Ensures that arrangements for equipment and other necessary items and services are available.
Instructs, supervises and evaluates home health aide care provided in accordance with state and federal regulations.