Major Responsibilities: Develops and maintains a therapeutic relationship throughout the healthcare continuum. Regularly communicates/consults with APC and MD Advanced Care at Home (ACAH) team regarding patient needs. Assesses patient's ongoing clinical status in person to determine healthcare needs or facilitates referrals to the needed community resources. Demonstrates the use of nursing process as a problem-solving model. Recognizes changes in clinical situations. Evaluates and implements changes to the plan of care. Plans, implements, coordinates, monitors and evaluate all options and services with the goal of optimizing the patient's health status, quality of life, and ability to remain in their home. Facilities the patient and family's right to receive quality, cost effective care. Mobilizes appropriate resources in response to situations that have the potential to negatively impact patient and family outcomes. Participates in quality/process improvement initiatives. Participates in efforts to reduce risk and improve patient safety. Educates patients and families regarding disease processes and trajectory and disease management. Demonstrated customer focused interpersonal skills to interact in an effective manner with practitioners, the interdisciplinary health care team, community agencies, patient and families with diverse opinions, values, and religious and cultural ideals. Demonstrates a commitment to meeting the learning needs of patients and families. Utilizes appropriate resources to meet those needs and achieve positive patient outcomes. Assists in creating an environment that promotes educational growth and opportunities for nursing peers and colleagues. Demonstrates respect and understanding for peers and other clinical disciplines and participates as an effective member of the patient care team to formulate an integrated approach to care. Demonstrates leadership behaviors and is committed to the development of self and others. Utilizes teaching, assessment, and intervention skills to provide long term or short term case management to those patients assigned. Responsible for continuous review of all aspects of every patient of her/his caseload to include appropriate utilization of services. Makes referrals to other team members as appropriate. Enters, completes and updates documentation in the electronic health record as required according to agency/department standards and policies, accreditation, state and federal guidelines. Documentation accurately records the patient's experience with a combination of assessments and narrative. Provides on-going assessment of patient response to treatments, medications and teaching while making appropriate changes in interventions and follow-up to meet patient needs. Communicates problems and changes in condition to providers. Enters, completes and updates documentation in the electronic health record as required. Documentation accurately records the patient's experience with a combination of assessments and narrative. Licensure, Registration, and/or Certification Required: Basic Life Support (BLS) for Healthcare Providerscertification issued by the American Heart Association (AHA), and A valid drivers license issued by the Division of Motor Vehicles, and Registered Nurse license issued by the state in which the team member practices. Education Required: Bachelor's Degree in Nursing. Experience Required: Typically requires 2 years of experience in home care nursing or 3-4 years of medical surgical experience. Knowledge, Skills & Abilities Required: Proficient use of patient care equipment Excellent telephone, interpersonal and written communication skills, And documentation Skills Computer proficiency including the ability to utilize software programs used by the organization. Good time management and organizational skills. Must be able to travel to all areas within the ACAH Program service area in all extremes of weather on all types of roads. Exposed to widely varying social and environmental conditions in patient's neighborhoods and homes. Required to make visits to private residences which may not be accessible to people with disabilities. Ability to work weekends, holidays, and different shifts in order to accommodate staffing. Ability to handle multiple tasks and complete work within short timeframes. Ability to respond quickly to patient needs and work at a fast pace. Work environment includes probability of exposure to adverse, hazardous, or unpleasant conditions while caring for the sick. Ability to respond to patients in a timely manner and access all areas of the unit. Physical Requirements and Working Conditions: Ability to lift up to 35 pounds without assistance. For patient lifts of over 35 pounds, or when patient is unable to assist with the lift, patient handling equipment is expected to be used, with at least one other associate, when available. Unique patient lifting/movement situations will be assessed on a case-by-case basis. This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.
