RN, Registered Nurse Hospice - Days

Community-Hospice Nurse, Case Manager

Job Summary: The Registered Nurse assesses, plans, directs and initiates the implementation of nursing care; coordinates therapy referrals and communicates with physician's offices, staff and patients/caregivers on medical orders received. Minimum Education: 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. Licensure, Registration and/or Certification: 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. Work Experience: None. Minimum 1 year of related experience, preferred. Knowledge, Skills and Abilities: Good interpersonal and communication skills. Basic computer skills. Reliable automobile for transportation as needed for home visits. Good clinical, interpersonal and communication skills. Essential Functions and 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. Decision Making: Independent judgment in making decisions involving non-routine problems under general supervision. Working Relationship: Coordinates activities of others (does not supervise). Works directly with patients and/or customers. Works with internal/external customers. Works with other healthcare professionals and staff. Special Job Dimensions: Must have reliable transportation, Saint Francis minimum amount of auto liability insurance and good driving record.