Patient Care/Care Coordination

· Ensures compassionate, empathetic quality and safe delivery of services to patients according to care plan.

· Consistently utilizes a patient-centered approach considering physical, psych/social, spiritual, educational, safety and related criteria appropriate to the age of the patients served in hospice.

· Integrates and coordinates the care of the at-risk population across the healthcare continuum making assessments, planning interventions working closely with providers and overall patient care team.

· Facilitates the interdisciplinary plan of care to meet multiple service needs as well as promote continuity through elimination of fragmentation of care/service.

· Delivers quality care consistent with Hospice Conditions of Participation, qualifying hospice criteria, payer coverage criteria, and providing visits/treatments consistent with the plan of care to honor patient/ family values/ wishes

· Makes visits to the homes of patients and assumes responsibility for an ongoing interdisciplinary assessment of the patient.

· Performs initial, comprehensive, and recertification assessments on all patients in accordance with agency policies and procedures.

· Performs nursing assessment at each visit in accordance with agency policies and procedures.

· Ensures quality and safe delivery of services to patients according to the care plan.

· Uses equipment and supplies safely, effectively, and efficiently.

· Provides education to patients and family members to understand the following as well as any additional education needs identified by the assessing clinician and/or physician:

o Medications purpose, use, side effects, potential adverse effects

o Proper use, safety hazards, and infection control issues related to the use and maintenance of any equipment provided

o Patient plan of care

o Emergency preparedness

o Disease progression and management of symptoms

· Provides the services that are ordered by the physician as indicated in the plan of care.

· Provides patient, caregiver and family counseling and education as indicated in the plan of care. Includes the patient, representative and caregiver in all plan of care decisions.

· Assesses the need for plan of care updates and every visit and includes the patient and family in care planning decisions and communicates care plan revisions to the patient, representative, caregiver and all physicians issuing orders for the home health plan of care.

· Maintains accurate and timely documentation of clinical records and time/travel entries.

· Receives, relays and documents verbal orders in accordance with state and federal regulations and in a timely manner to prevent adverse patient outcomes.

· Is responsible for obtaining physician orders prior to initiation of care and notifying the physician of any changes in the patient’s condition.

· Communicates with all physicians involved in the plan of care and other health care practitioners related to the current plan of care.

· Identifies patient’s risks for hospitalization and/or emergency department use and proactively intervenes to prevent adverse events.

· Supervises home health aide and licensed practical nurse staff and documents supervision in the patient medical record.

70%

Hospice Performance Criteria

· Delivers quality care and completes clear, concise and accurate clinical documentation of care provision in accordance with home health conditions of participation (CoPs), various payer home health coverage criteria, accreditation standards, professional standards for discipline/credential and the home health plan of care.

· Maintains competence in HIS data collection and documentation and submits all initial and corrected assessments according to CMS guidance and agency policies and procedures.

· Participates in clinical review of records to monitor quality and accuracy, appropriate utilization, appropriate involvement of interdisciplinary team members, appropriate referrals and coordination of care.

· Participates in peer review and other quality assurance activities, as assigned.

· Uses appropriate infection control procedures and safety measure to protect employees and patients.

· Provides patient and family education using UPaH approved patient teaching materials only.

· Participates in IDT, in-service programs and other meetings required to ensure coordinated and comprehensive care.

· Reviews all patient assignments prior to scheduling first visit and accepts patient assignments only for which qualified and competent in any specific care/technical skill/procedure needed.

· Participates as a member of the interdisciplinary team.

· Participates in quality assurance/performance improvement (QAPI) activities, as assigned.

· Maintains professional knowledge for discipline/credential/license ensuring inclusion of content specific to home and community based care.

· Communicates professionally, effectively and timely to all team members and co-workers and responds to all communication in a timely manner including, but not limited to e-mails, phone communication and meeting follow-up responsibilities.

· Establishes and maintains positive interpersonal relationships with team members, patients and family members while maintain personal and professional boundaries.

· Assist with new employee orientation when necessary.

· Effectively plans, organizes, sets priorities and completes works assignments with minimum direct supervision per agency policy and within established time frames.

· Maintains productivity standards as defined by home care supervisor.

· Meets or exceeds agency expected outcomes related to patient experience and quality of care.

· Participates in evening, night and weekend coverage to ensure nursing services are accessible to all patients 24 hours a day, 7 days per week (schedules and rotations determined by region).

· Performs other duties as assigned by Hospice clinical supervisor and/or administrator.

20%

Basic UPH Performance Criteria

· Demonstrates the UnityPoint Health Values and Standards of Behaviors as well as adheres to policies and procedures and safety guidelines.

· Demonstrates ability to meet business needs of department with regular, reliable attendance.

· Employee maintains current licenses and/or certifications required for the position.

· Practices and reflects knowledge of HIPAA, TJC, DNV, OSHA and other federal/state regulatory agencies guiding healthcare.

· Completes all annual education and competency requirements within the calendar year.

· Is knowledgeable of hospital and department compliance requirements for federally funded healthcare programs (e.g. Medicare and Medicaid) regarding fraud, waste and abuse. Brings any questions or concerns regarding compliance to the immediate attention of administrative staff.

· Takes appropriate action on concerns reported by department staff related to compliance.

· Maintains compliance with Personnel policies and procedures.

· Behaves in a manner consistent with all Corporate Compliance policies and procedures.

10%

Disclaimer: This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that required of the employee. Other duties, responsibilities and activities may change or be assigned at any time with or without notice.

Demonstration of UPH Values and Standards of Behaviors

Consistently demonstrates UnityPoint Health’s values in the performance of job duties and responsibilities

Foster Unity:

· Leverage the skills and abilities of each person to enable great teams.

· Collaborate across departments, facilities, business units and regions.

· Seek to understand and are open to diverse thoughts and perspectives.

Own The Moment:

· Connect with each person treating them with courtesy, compassion, empathy and respect

· Enthusiastically engage in our work.

· Accountable for our individual actions and our team performance.

· Responsible for solving problems regardless of the origin.

Champion Excellence:

· Commit to the best outcomes and highest quality.

· Have a relentless focus on exceeding expectations.

· Believe in sharing our results, learning from our mistakes and celebrating our successes.

Seize Opportunities:

· Embrace and promote innovation and transformation.

· Create partnerships that improve care delivery in our communities.

· Have the courage to challenge the status quo.

License(s)/Certification(s):

-Valid license as RN in state(s) where providing care

Valid licensed driver with automobile insurance in accordance with state(s) and/or organizational requirements.

-Mandatory Reporter: Child & -Dependent Adult Abuse.

-Person Centered Care (PCC) course completion within first 12 months of hire and annual completion of competency validation activities.

-CPR: Maintain a valid Basic Life -Support (BLS) Healthcare Provider Card with Re-certification.

CHPN certification

Knowledge/Skills/Abilities:

Basic knowledge of current, frequently used medications, including modes of administration, actions and side effects.

Competency in variety of nursing skills and ability to perform without supervision (NPWT, complex wound care, IV therapy, catheter care, ostomy care, chronic disease management assessment and teaching).

Strong interpersonal skills.

Ability to work as a collaborative team member.

Ability to understand and apply guidelines, policies and procedures.

Ability to navigate and perform basic use of Microsoft Office products.

Maintains a reliable mode of transportation and has the ability to drive safely during all day and night hours and in all types of inclement weather.

Experience with documentation in an electronic health record.

Other:

Use of usual and customary equipment used to perform essential functions of the position.