Registered Nurse, Home Care

Mass General Brigham•Chelsea, MA

1d•Hybrid

About The Position

Mass General Brigham Home Care is seeking a per diem Registered Nurse to join their "Beantown" team. This team provides care to patients from around the world who come to Boston for medical treatment. The role involves serving as a case manager, overseeing the full plan of care, and collaborating with LPNs, therapists, and social workers. RNs typically complete 5-6 visits per day, Monday through Friday, with built-in time for documentation, chart review, and coordination. Mass General Brigham Home Care focuses on providing non-acute, medically necessary skilled care in the home to help "homebound" patients recover from illness or injury and manage chronic diseases. Services include skilled nursing care, physical therapy, occupational therapy, speech language pathology, medical social services, and medical supplies. They are looking for experienced, emotionally intelligent Registered Nurses who thrive in autonomous roles and are dedicated to delivering high-quality, compassionate care. Candidates should be confident in their clinical decision-making, organized in their time management, and comfortable navigating a dynamic home-based environment.

Requirements

Graduate of an approved School of Nursing
Current Massachusetts license as Registered Nurse
Minimum of one year previous nursing experience in acute care setting.
Travel required within MGB Healthcare at Home geographic area
Ability to work with various computer software required
Strong interpersonal and customer service skills
Ability to work with a diverse population
Ability to communicate effectively in writing, verbally and electronically
Ability to organize and prioritize work, and adapt to changing situations
Ability to work independently, be self-directed and adapt to unpredictable circumstances
Ability to work as a member of an interdisciplinary team of health care providers

Nice To Haves

Prior home care experience preferred
Knowledge of hand-held patient care computer devices preferred

Responsibilities

Provide quality, clinical services to patients in various settings in the community.
Deliver patient care within organizational philosophy, policy and standards of community health practice.
Perform admissions process and case management responsibilities in accordance with Mass General Brigham Home Care policies and standards of practice, utilizing thorough and timely electronic documentation and interdisciplinary communications.
Provide skilled nursing care in the form of assessment, teaching, treatment, documentation, and care coordination demonstrating high quality customer service, and financial awareness.
Develop and periodically update the plan of care to address patient-specific needs, preferences, hospital readmission and infection risk, home safety and clinical conditions to ensure optimal patient safety and outcomes.
Communicate patient information and change in status/plan of care to physician and document in a timely manner in accordance with agency standards.
Reconcile medications accurately at SOC, ROC and Transfer, and integrate changes into the plan of care. Review medications at each visit.
Order medical supplies according to allowable guidelines and manage wound supplies in consultation with the WOCN.
Establish and submit patient schedule timely. Routinely adjust schedules and communicate timely with the Clinical Manager and the Scheduler to meet patient and agency needs.
Adhere to Point of Care standards for submission of data no later than midnight of the day of the visit/admission, including closed and sync’d encounters (exceptions to this standard must be reported to Clinical Manager or designee in the same time period).
Update software by maintaining the latest version of software applications as defined by the IS Department.
Prepare and effectively communicate patient information to appropriate departments and team members in accordance with agency standards.
Make referrals to other disciplines and to appropriate community resources to meet patient-specific needs and maximize patient safety and outcomes.
Identify patients for multi-disciplinary case conferences as needed after Start of Care.
Provide patient education in the patient’s preferred language and format from time of admission and evaluate on an ongoing basis to meet the needs and abilities of patients and families and is appropriate to the care and treatment provided. Document teaching and pt/cg response clearly in the medical record.
Initiate discharge planning (that includes the primary physician, family, and patient and accesses community resources) at Start of Care and evaluate on an ongoing basis for optimal patient safety and outcomes and ensure it is evident on review of the medical record.
Complete all patient consent/notification forms as required by Agency policy, law, and regulations, and submit to the office within 24 hours.
Inform patients of and obtain consent for planned visits/visit schedule.
Deliver services in a timely manner and in accordance with patient needs and preferences as evidenced by adherence to the plan of care. Contact patients if visits will be late or rescheduled and notify physicians if care is or will be impacted.
Actively include patients and their families in the care planning process.
Clearly document patient notification of and consent to any and all changes in the medical record.
Consistently demonstrate quality patient care by adherence to standards of care, appropriate and timely communication, coordination of care, and completion of required clinical documentation.
Perform assignments at a complex level, supported by documented competency, including but not limited to high tech visits, end of life care, complex wounds, etc.
Attend staff meetings, competencies, training and educational meetings regularly (suggest a standard such as 80% of the time). Attend or complete 100% of all mandatory education.
Support clinical initiatives and special training (e.g. EOL lifeline, etc.).