The Home Care Registered Nurse (RN) plans, organizes and directs home care services and is experienced in nursing with emphasis on community health education/experience. The RN builds from the resources of the community to plan and direct services to meet the needs of individuals and families within their homes and communities.
Patient Care Completes an initial home health assessment of patient and family to determine home care needs, and provides a complete physical assessment and history of current and previous illness(es). Completes initial, comprehensive and ongoing assessments of patient and family to determine hospice needs, and provides a complete physical assessment and history of current and previous illness(es). Conducts home visits as assigned, assessing the patient's condition, progress toward goals, providing patient care, teaching, and other skilled interventions as ordered. Regularly re-evaluates patient nursing needs, as part of nursing visit.
Initiates the plan of care and makes necessary revisions as patient status and needs change in collaboration with Case Manager. Uses health assessment data to determine nursing diagnosis and develops a care plan that establishes goals based on nursing diagnosis and incorporates therapeutic, preventive, and rehabilitative nursing actions, and includes the patient and family in the planning process. Initiates appropriate preventative and rehabilitative nursing procedures, and administers medications and treatments as prescribed by the physician.
Counsels the patient and family in meeting nursing and related needs. Provides health care instructions to the patient as appropriate per assessment and plan of care. Identifies discharge planning needs during nursing visits, communicates needs to team as part of the care plan development, and assists in implementing prior to discharge of the patient.
Communication Prepares home health clinical notes and updates the case manager and primary physician when necessary.
Completes, maintains and submits accurate and relevant hospice clinical notes regarding patient's condition and care given, and records pain and symptoms management changes and outcomes as appropriate. Prepares clinical notes and updates the primary physician and/or Medical Director (Hospice) when necessary.
Communicates with the physician regarding the patient's needs, and reports any changes in the patient's condition, and obtains and receives physician's order as required. Teaches the patient and family/caregiver self-care techniques as appropriate, provides medication ,diet and other instructions as ordered by the physician, and recognizes and utilizes opportunities for health counseling with patients and families/caregivers. Works in concert with the hospice interdisciplinary group or home health interdisciplinary team.
Communicates with community health related persons to coordinate the care plan. Attends home health care conference and/or interdisciplinary group meetings as requested. Additional Duties Participates in on-call duties as defined by the on-call policy.
Ensures that arrangements for equipment and other necessary items and services are available. Instructs, supervises, and evaluates home health care aides. Actively participates in quality assessment performance improvement teams and activities.
Qualifications / Requirements:
Minimum of two years experience, at least one of which is in the area of public health, home care, or hospice nursing, is preferred
Graduation from an accredited school of nursing is required
Licenses / Certifications:
Registered nurse with current licensure to practice professional nursing in New York State, CPR certification
The individual performing this job may reasonably anticipate coming into contact with human blood and other potentially infectious materials.
Health Alliance Of Hudson Valley