RN, Registered Nurse, Home Health - Days

Saint Francis Health System

About The Position

The Registered Nurse assesses, plans, directs, and initiates the implementation of nursing care, coordinating therapy referrals and communicating with physician's offices, staff, and patients/caregivers regarding medical orders. This role involves performing assessments to determine patient eligibility and needs for home health services, developing and revising patient-centered plans of care, and delivering nursing care with consideration for cultural, psychological, functional, cognitive, and social determinants. The nurse is responsible for organizing and prioritizing case management, demonstrating professional judgment in response to changes in patient status, and completing assigned work within productivity standards. Key functions include identifying ongoing patient needs, initiating timely referrals, coordinating care with the healthcare team, and managing daily laptop communication and updates. The position also requires reviewing and communicating medication issues, maintaining updated medication lists, and establishing effective medication systems within the patient's home. Documentation of patient care in the EMR, including coordination of care and progress toward goals, is essential. The nurse develops and revises Home Health Aide plans, conducts supervisory visits, performs nursing skills according to physician orders, and instructs patients and families on emergency, safety, and home management of their illness. Ensuring ongoing patient and caregiver education for discharge planning and communicating discharge plan revisions to all relevant parties are also critical. The role supports agency goals through various analyses and conferencing, assists with orientation, and complies with infection control plans.

Requirements

Has completed the basic professional curricula of a school of nursing as approved and verified by a state board of nursing, and holds or is entitled to hold a diploma or degree therefrom.
Valid multi-state or State of Oklahoma Registered Nurse License.
A valid driver's license and a Motor Vehicle Report that meets SFHS guidelines are required.
Minimum 1 year of related experience.
Good interpersonal and communication skills.
Basic computer skills.
Reliable automobile for transportation as needed for home visits.
Good clinical, interpersonal and communication skills.

Nice To Haves

1 year of related experience

Responsibilities

Performs assessment to determine the patient's eligibility and needs for home health services.
Develops & revises a patient-centered plan of care based upon the patient's strengths, stated goals and care preferences.
Delivers nursing care with consideration for the patient's cultural, psychological, functional, cognitive & social determinants.
Includes the patient & family in the care planning process.
Organizes & prioritizes case management responsibilities including complex tasks.
Demonstrates professional judgment in response to changes in patient's status and agency's constraints.
Completes assigned work within allotted time within the productivity standard.
Identifies ongoing patient needs, initiates appropriate and timely referrals & coordinates care with the health care team.
Completes daily laptop communication and downloads updates timely.
Reviews all medications the patient is using in order to identify any potential adverse effects, drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and non-compliance with drug therapy.
Communicates any medication issues with the health care team.
Keeps an updated medication list in the home.
Demonstrates knowledge of resources & initiates measures to establish an effective medication system within the patient's home.
Documents patient's care on the appropriate forms in EMR.
Accurately records data accurately in the EMR according to the plan of care.
Utilizes correct medical terminology and abbreviations.
Documents coordination of care and progress toward goals and outcomes.
Develops and revises the Home Health Aide plan based upon the ability for the agency to safely meet the patient's needs with their ADL's and IADL's.
Conducts & documents the Home Health Aide supervisory visit at least every 14 days.
Performs nursing skills in accordance with assessed needs and physician orders.
Anticipates and delivers patient care according to agency processes and policies.
Instructs patient and families in emergency, safety, and home management of their disease or illness.
Demonstrates knowledge and proficiency in clinical skills required in the home health field.
Ensures that each patient, and/or caregiver, receive ongoing education and training regarding the care and services in the plan of care, to ensure a timely discharge plan.
Communicates any revisions of the plans for patient's discharge to the patient, representative, caregiver, physicians and health care team who will be responsible for providing care and services to the patient after discharge from the agency.
Supports agency hospital goals through SHP analysis, PDGM case conferencing, one on one case conferencing, QA, educational standards and QAPI.
Makes QA/SHP changes timely and accurately.
Modifies behaviors or performance to comply with standards and meet thresholds.
Assists with orientation process as directed.
Supports an interdisciplinary team approach.
Complies with the Home Health Infection control plan.
Follows the infection control policies and practices of the agency.