The Patient Care Coordinator, Home Health, supervises the delivery of patient care by maintaining contact with the nursing staff, physicians, patients, and their families.
Coordinates the delivery of care to patients by communicating effectively with referral sources, physicians, patients, families, and other providers.
Oversees and coordinates all components of care provided to managed care patients. Makes critical decisions to expedite the appropriate and timely delivery of services. Utilizes the strengths of the team to provide multi-disciplinary interventions and follow-ups, and redirects as necessary to reach patient care goals.
Responds to employee reports of unsafe conditions and takes corrective action. Identifies potentially unsafe conditions for patients/families whether emotional, physical, psychosocial, or environmental in nature and takes corrective action. Works closely with counselors/social workers to create and implement a plan to manage unsafe situations.
Complies with safety policies and procedures at all times and informs the Manager of any unsafe conditions. Follows basic infection control procedures and uses standard precautions. Recognizes emergencies and demonstrates knowledge of emergency procedures.
Maintains and directs the judicious use of the organization's equipment, materials and supplies to meet patient needs and reports malfunctions or defects. Identifies/reviews the appropriate need for equipment with admitting RN, facilitates delivery, and assists in changing equipment as patient condition changes. Respects the property of patients and their families.
Orients newly hired staff to the coordination functions and processes of the Patient Care Coordinator role and to their responsibilities to keep him/her informed of patient care information. Consults, coaches, and mentors interdisciplinary team members (especially clinical nursing) to assure the provision of excellent patient care, continuity, problem solving and appropriate decision-making, and strong, effective communication. Participates in staff meetings and inservice training.
Coordinates all aspects of the patient/family Plan of Care from point of admission through condition changes and/or discharge.
Reviews referrals from the Central Intake Department to create a proactive plan of care and arrange for efficient admission. Works closely with scheduler/team assistants to assign the appropriate staff members; review insurance information, and arrange for services as ordered (e.g., DME, IV supplies). Adjusts visits to promote continuity of care, minimize travel, and accommodate admissions and emergency visits. Advocates for patient/family needs in all arenas (MD, facilities, and community organizations). Represents VNA in a professional and mature manner at all times. Contacts newly referred patients/families to inform them of the pending admission and any insurance concerns. Reviews and communicates laboratory test results, and obtains necessary orders. Directs LPNs through provision of care. Functions as a liaison between field staff, MDs and other services.
Provides input to the Manager for performance appraisals. Assists and supports patient/family through physical and/or emotional crises.
Advocates for the well-being and wishes of the patient to family members, doctors, and others. Consistently practices basic principles of customer service theory with all internal and external contacts. Makes skilled nursing visits as necessary. Supports patient/family through palliative measures. Provides 24 hour, 7 day a week supervisory support to field staff in scheduled rotation. Accepts other duties as assigned. Follows the organization's policy regarding the confidential treatment of patient, employee, and proprietary information (including HIPAA). Identifies areas which may present compliance problems with federal regulations for the position's assigned responsibilities. Follows the organization's policies and procedures in order to maintain compliance with federal regulations. Suggests monitoring procedures and reports suspected violations.
Coordinates and distributes updated information to physicians, or other providers appropriately. Provides input into the plan of care and assures the plan of care is an evolving tool for directing patient care. Establishes and maintains effective working relationships with physicians, contracted facilities, and community services. Communicates appropriate patient/family information to the physician in a timely manner. Presents a positive attitude and confident approach, through change; and supports organizational activities and processes directly benefitting the entire VNA Family of Services.
Actively supports team members in every aspect of care and daily responsibilities. Recognizes the extraordinary efforts of the team and individuals as appropriate.
Problem-solves to creatively use available resources to meet patient/family and staff needs. Demonstrates self-direction to identify difficulties and to utilize available resources efficiently. Participates in continuous quality improvement activities. Makes suggestions for changes to improve organization systems and processes. Ability to manage, direct, and organize the multiple demands of hospice, managed care and home care. Seeks ongoing education to advance clinical expertise. Recognizes the importance of empowerment in problem-solving and decision making. Communicates in a clear concise manner, with the recipient's perspective in mind.
Demonstrates willingness to learn and/or ability to use current technology such as personal computers, software and medical equipment.
Performs other duties as assigned.
Currently licensed as a Registered Nurse in Pennsylvania.
One year of experience in hospital, medical/surgical nursing, public health nursing or related experience.
Prior home health, hospice, psychiatric, and or mental health nursing experience preferred.
Working knowledge of computers, Microsoft Word and Excel required.
Must have dependable transportation with a valid driver's license. Independently visit patients in their homes.