Home Health - RN Case Manager - Full Time - Days AdventHealth Waterman
Top Reasons To Work At AdventHealth Waterman
Career growth and advancement potential
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Location - Travel locally 100%
Full Time, Days with weekend rotation
GENERAL SUMMARY: The Home Health Registered Nurse (RN) Care Manager is a professional nurse who coordinates and directs the home care patients care based on individual patient needs. The RN Care Manager is responsible for independent management of the Home Health patient population requiring the use of advanced assessment, teaching and decision-making skills. The nurse is responsible for ensuring that appropriate referrals to other services are made, interdisciplinary conferencing takes place regularly, and appropriate documentation is completed. Relevant knowledge and experience is consistently applied to new patient populations. The Care Manager cares for a caseload of home health patients by evaluating the patient for appropriateness of home health and developing the home care plan in conjunction with the physician. S/he educates patients, families, caregivers and community providers to safely perform care. S/he provides follow up by evaluating effectiveness of the home care plan, and monitoring patient/familys response to the plan to achieve patient/family goals and top decile outcomes. The Care Manager also identifies performance improvement and home health standard of care initiatives and assists to design or implement programs to address needed changes.
PRINCIPAL DUTIES AND JOB RESPONSIBILITIES:Â· Coordinates and directs the care of a caseload of home patients when the primary skill needed is nursing. Provides comprehensive assessment, planning, implementation and evaluation for that caseload as the primary nurse. · Sets priorities of home care caseload adapting to the changing needs of the home care patients and families. Optimizes schedule daily to support productivity, efficiency and maintain best practice visit utilization. · Assesses physical, functional, psychosocial, social, spiritual, educational, developmental, cultural, cognitive status and discharge planning needs of the home care patient utilizing interview observations and physical exam techniques. Assesses the home environment for safety, infection control, and community resource needs. Reviews patient history and physical, diagnostics and laboratory data. Reviews available information obtained by other team members. Reports abnormal items and results to the physician as appropriate and reviews with patient family. Accurately and timely documents these assessments. · Utilizing assessment data, formulates a patient specific plan of care along with the patient, family and physician which is feasible within the physical, financial and emotional resources of the family. Establishes individualized, realistic, measurable patient centered goals in consultation with the patient, family and other health care providers including goals to improve or stabilize patientâ€™s medical condition, functional abilities and promote independence. Considers the physical, cultural, psychosocial, spiritual, age specific and educational needs of the patient when developing the plan of care. · Implements the plan of care through direct patient care, coordination, delegation and supervision of the activities of the health care team. Provides care based on physicianâ€™s orders, in compliance with policies and procedures, standards of care, and regulatory requirements. Delegates appropriately and provides nursing supervision in the provision of care to patients by other licensed nurses and other personnel. Promotes continuity of care by accurately and completely communicating to other caregivers the status of patient for whom care is provided. Provides skilled nursing care, preventative rehabilitative procedures, and prescribed treatments with a variety of patient populations within various potentially complex home situations. · Uses motivational interviewing/health coaching techniques to engage key stakeholders in the management of care. Evaluates patients and familys responses to care and teaching and effectiveness of teaching based on a continuing assessment and analysis of nursing intervention and alternatives for nursing care. Ensures that the home care patient and family demonstrate the knowledge and abilities regarding home care rights and responsibilities, diagnosis, health care status, treatment, skills, medication regime, advance directives, and adaptive behaviors gained as a result of teaching interventions. Initiates change in the care plan as needed. · Informs the physician, clinical manager, and other appropriate members of the health care team of changes in the patients condition and needs. Facilitates and coordinates interdisciplinary care conferences with groups of complex patients. · Maintains an updated clinical record on each patient at all times, meeting required deadlines for documentation of certification, re-certification, aide supervision reports, aide care plan updates, routine recording of case coordination, care plan updates, addressing progress toward goals, and verbal orders. · Provides care based on the best evidence available and may participate in research activities within clinical practice. Interacts and participates in the education, role development, and orientation of agency personnel promoting and supporting growth of other through precepting and mentoring as needed. Takes ownership to optimize agency performance through active involvement in quality improvement activities.
KNOWLEDGE AND SKILLS REQUIRED: · Functions with a high degree of independence · Ability to delegate tasks to appropriate personnel as indicated by skill level and professional standing · Strong computer and technology skills
EDUCATION AND EXPERIENCE REQUIRED: · Minimum of one-year relevant clinical RN experience
LICENSURE, CERTIFICATION OR REGISTRATION REQUIRED: · Current Registered Nursing License in State of Practice · Valid Drivers
At AdventHealth, Extending the Healing Ministry of Christ is our mission. It calls us to be His hands and feet in helping people feel whole. Our story is one of hope — one that strives to heal and restore the body, mind and spirit. Our more than 80,000 skilled and compassionate caregivers in hospitals, physician practices, outpatient clinics, urgent care centers, skilled nursing facilities, home health agencies and hospice centers are committed to providing individualized, wholistic care.