ProMedica RN Home Care in Monroe, Michigan
Responsible to the Director of Professional Services, Patient Care Coordinator to provide nursing care and case management to patients and families. Implements nursing interventions and coordinates the patient/family interdisciplinary plan of care. Supervises personnel to deliver care and coordinates care delivery.General Responsibilities- Manages a patient and family caseload which includes assessing, planning, implementation, evaluating and documenting the care provided.- Plans, coordinates and delivers nursing care to patients and families.- Supervises and documents home health aide/licensed practical nurse plans of care and documents supervisory visits.- Participates in on-call coverage.- Submits paperwork in a timely manner and updates and maintains patient medical records.- Participates in regularly scheduled interdisciplinary team meetings to coordinate the care of the patient and family, exchange information and problem solve, and receive staff support and education.- Applies the policies and procedures of the agency and the rules and regulations of Federal and State regulatory agencies and other certifying agencies in providing care.- Coordinates and develops patient/family plan of care and ensures the care plan is current, up to date and reviewed at every team meeting.- Assesses evaluates patients level of care, needs and requirements.- Participates in agency quality assessment performance improvement (QAPI) programs.- Ensure growth profitability of the company through the responsible use of company resources and educating the community to our services.- Assesses the patient's response to the Plan of Care and recommends changes as needed.- Meets or exceeds established productivity standards.- Provides education to the patient/family regarding the disease process, self care techniques, prevention strategies, rehab nursing procedures and community resources for discharge planning- Initial and ongoing comprehensive assessment of patient's needs including Outcome and Assessment Set (OASIS) at appropriate time sets.- Evaluating Outcomes of Care.- Provide counseling to patient/family regarding disease process, end of life and ethical issues.- Willingly accepts direction from Director of Professional Services/PCC.- Participates in community programs and committees, as requested.- Supervises LPN/LVNs, home health aides and paraprofessionals providing services to the patient according to regulatory guidelines.- Monitors that documentation from LPN/LVN, home health aides are complete.- Participates in in-service programs- Assesses the ability of the caregiver to meet the patient's needs at admission and throughout care.- Evaluates patient/family response to care on an on-going basis. Communicates information using current process and technology available to the organization- Ensures that employees are adequately oriented and trained to assignment; assists and encourages employees in developing their skills and self-confidence.- Initiates appropriate preventive and rehabilitative nursing procedures. Prepares clinical progress notes that demonstrate progress towards goals. Coordinates patient/family services and prioritization of needs with members of the interdisciplinary team. Uses case management approach and refers to other services as needed. Informs the physician and other personnel of changes in the patient's needs and outcomes of intervention. Determines scope and frequency of services needed based on acuity and patient/family need.- Adheres to established personnel policies.- Accepts other assignments deemed appropriate.