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Have two years home health experience
Bilingual is a plus
Essential Job Functions/Responsibilities
Responsible for continuous review of all aspects of every patient on his/her caseload to include: appropriate utilization of services; ensuring continued skilled need; monitoring of homebound status; review of documentation in the medical record; maintenance of interdisciplinary communication and discharge planning.
Completes an initial assessment of patient and family to determine home care needs. Provides a complete physical assessment and history of current and previous illness(es). Admits to appropriate level of service/ care.
Uses health assessment data to determine nursing diagnosis.
Initiates the plan of care and makes necessary revisions as patient status and needs change.
Develops a care plan, which establishes goals based on nursing diagnosis and incorporates therapeutic, preventive, and rehabilitative nursing actions. Includes the patient and the family in the planning process.
Regularly re-evaluates patient nursing needs.
Counsels the patient and family in meeting nursing and related needs.
Provides health care instructions to the patient as appropriate per assessment and plan.
Provides supervision of LVNâs and home health aides per CHAP standard and regulatory requirements.
Responsible to reassess the patient within 24 hours following a change in condition or discharge from an inpatient setting. Case manager should be the first RN to visit the patient status post hospitalization; updates the plan of care.
Identifies discharge planning needs as part of the care plan development and implements prior to discharge of the patient.
Knowledge of state, federal, local and accreditation (CHAP) regulations for the delivery of home health services.
