OASIS RN Weekend - HomeCare

Hartford HealthCare at Home•Bridgeport, CT

8d•Onsite

About The Position

Provides skilled nursing care to clients in their homes or community health settings ensuring the delivery of outcome based, high quality, cost effective care. This role focuses on completing OASIS assessments with accurate scoring of clinical & functional questions and developing a plan of care in collaboration with the client and all disciplines. The position involves making follow-up visits, teaching patients and caregivers, coordinating care with providers, and directing LPNs and Home Care Aides.

Requirements

Graduate of an Associate’s Degree or diploma program in nursing
One year nursing experience or one year nursing experience in a specialty
Registered nurse with a license to practice in the state of CT

Responsibilities

Reviews referrals, and initiates contact with client and family.
Conducts a complete nursing assessment based on referral data, client/family interview, and clinical observation of patient health status.
Focus on completing the OASIS assessment with accurate scoring of clinical & functional questions.
Develops a plan of care in collaboration with client and all disciplines based on assessment data which documents need for services, appropriate discharge planning, short- and long-term goals, and utilization of appropriate resources.
Provides OASIS time point assessments throughout a patient’s episode which provides objectivity and consistency.
Initiates and maintains a client record utilizing the Agency’s standard for documentation.
Makes follow-up visits to provide skilled care to assess disease progress and evaluates response to treatment; provides support to client/family utilizing teaching principles to promote and restore health and prevent disease and disability; coordinates care with providers.
Teaches patients and reinforces client/caregiver teaching and education.
Refers, collaborates, and coordinates all client care services.
Consults with physician regarding client needs and plan of care.
Directs LPNs in carrying out the established plan of care.
Directs Home Care Aides and supervises plan of care.
Refers client/family to other community resources as needed.
Attends and participates in in-service education program.
Seeks consultation and guidance from supervisor.
Participates in the evaluation of care given by paraprofessional staff.
Participates in health care programs.
Completes reporting requirements on a timely basis.
Participates in client care conferences, staff, and group meetings, IDT, and LEAN Process Management.
Participates in daily SBAR report with nurse care coordinator.
Maintains productivity standard.
Assumes the role of team leader on a rotating basis.
Performs other duties as assigned.