Coordinates patients’ interdisciplinary plan of care through assessment and evaluation of patient condition and effectiveness of care under the direction of the attending physician by traveling to patient homes, Community-Based Residential Facilities (CBRF), assisted living locations, hospitals or other to meet patient and family/caregivers, assess patient care needs, acuity in relation to regulations of home care and/or hospice services.

PRIMARY RESPONSIBILITIES

• Collaborates with the patient, family and healthcare team to develop a comprehensive plan of care based on the unique needs of the patient. Responds to calls from patients, family members and others, completes follow-up to address needs, issues, or concerns.
• Provide skilled nursing care within the established plan of care, including performance of tasks such as taking vitals, performing wound care, IV care, ostomy care, blood draws, injections, and the physical assessment of the overall patient’s medical condition. Conducts patient admissions and routine visits.
• Continually evaluates the patient’s condition and the effectiveness of treatments, plan of care, medications, and therapies. Reviews, sets-up, and administers medications as necessary per the established plan of care.
• Documents visit notes, treatments, and care. Follows visit pattern according to physicians orders and ensures required visits are completed in a timely manner. Ensures all documentation is timely, accurate and complete in adherence to regulations.
• Collaborates, consults and communicates with physician regarding the plan of care and changes to patient status. Provides physician with regular updates on progress and recommends revision of plan care, documents status and communication in adherence with regulations.
• Coordinates and communication with multi-disciplinary team members and outside agencies as appropriate to achieve expected outcomes for patient care and education through end of life or discharge, ensuring accurate and complete documentation and coordination of unique care plan.
• Provide instruction and direction to other nursing staff regarding patients. Monitors and reviews the provision of care provided, communicates concerns to supervisor. Provides instruction and training as necessary. Reviews documentation to ensure compliance to the plan of care.
• As an SSM Health nurse, I will demonstrate the professional nursing standards defined in the professional practice model. Uses the ANA Code of Ethics for Nurses to guide his/her response to the current and evolving health and nursing needs of our patients and our patient populations.
• Works in a constant state of alertness and safe manner.
• Performs other duties as assigned.

EDUCATION

• Graduate of accredited school of nursing

EXPERIENCE

• One year experience

PHYSICAL REQUIREMENTS

• Frequent lifting/carrying and pushing/pulling objects weighing 0-25 lbs.
• Frequent sitting, standing, walking, reaching and repetitive foot/leg and hand/arm movements.
• Frequent use of vision and depth perception for distances near (20 inches or less) and far (20 feet or more) and to identify and distinguish colors.
• Frequent use of hearing and speech to share information through oral communication. Ability to hear alarms, malfunctioning machinery, etc.
• Frequent keyboard use/data entry.
• Occasional bending, stooping, kneeling, squatting, twisting and gripping.
• Occasional lifting/carrying and pushing/pulling objects weighing 25-50 lbs.
• Rare climbing.
• Frequent Driving.