Role Overview: Responsible for patient care planning, care coordination, service utilization, and interdisciplinary team education to ensure patient-centered care with optimal outcomes.
Key Responsibilities:
- Perform comprehensive assessments and develop individualized care plans in collaboration with physicians and the care team.
- Utilize clinical expertise to make recommendations based on physical, psychosocial, emotional, spiritual, and bereavement assessments.
- Implement nursing processes during Start of Care visits, evaluations, re-certifications, discharges, and supervisory visits.
- Coordinate and modify care plans, identifying significant changes in patient condition requiring documentation like OASIS.
- Educate patients, families, and caregivers on disease management, self-care, and community resources.
- Promote resource efficiency and adherence to clinical protocols to achieve positive patient outcomes.
Qualifications & Skills:
- Registered Nurse (RN) license in the state of practice.
- Strong assessment, communication, and problem-solving skills.
- Ability to educate and influence patient behavior effectively.
- Preferred 1-3 years of experience in home health or hospice care.
Core Values & Standards: Commitment to compassionate care, teamwork, confidentiality, and compliance with safety and regulatory standards such as CMS, OSHA, and The Joint Commission.