Overview

Provides services, treatments and procedures for patients that are ordered by authorized practitioners and in accordance with agency policies and standards of clinical practice. Implements the nursing process in developing, implementing and assessing the efficacy of the care delivered and revising the plan of care, as needed. Develops and evaluates the plan of care that occurs in partnership with the patient, representative (if any), and caregiver. Works under moderate supervision.

Responsibilities
• Performs initial and ongoing supervisory field visits to patients’ homes to provide assessment, training support, in-home coordination and/or crisis management. Conveys any significant changes in the patient’s condition, emergency intervention, or care plan changes. Reports all interventions made to the clinical manager and documents findings electronically. • Collaborates with the primary care physician and clinical team to gather the patient’s medical history, medication, and other pertaining information to perform a thorough patient assessment. • Educates and reviews the paraprofessional plan of care with the Home Health Aide (HHA). • Provides Infusion Therapy such as Venous blood draws, Central line blood draws, Peripheral line placement, IV Medication administration and training PICC and Midline maintenance/dressing change in patient homes along with patient education in accordance with the physicians. • Assesses patient needs and physical status at each visit through reviewing patient health data and completing patient interviews. • Re-evaluates patient needs through physical reassessment, response to therapy, and supplemental physician orders. • Obtains and clarifies physician orders for plan of treatment revisions, informs physician promptly of significant changes in patient's condition, and provides written summary to physician within supplemental order. • Provides effective and safe teaching using patient-centered care approach for patients and their family to achieve independence with prescribed therapy and care needs through active participation per plan of treatment goals. • Effectively and timely communicates with VNS Health’s Clinical team, medical providers, patients, and families/caregivers to facilitate continuity of care. • Prepares clinical documentation in real-time during visits and submits to the nursing department to comply with established timelines for billing optimization. • Completes all documentation legibly and applies approved abbreviations and documentation error correction practices per VNS’s policy. • Coordinates discharge planning and prepares discharge summaries with patient instructions and thoroughly reports patient care needs, progress and goals when transferring care. • Applies clinical IV experience and personal touch to assist with the patient’s recovery in the comfort of their own home. • Provides nursing care in accordance with VNS Health policies, practices, procedures and Standards of Nursing Practice, which may require standing, stooping, sitting, crouching, bending and stretching to deliver patient care. • Transports and utilizes required medical equipment and other supplies using VNS Health designated/supplied carrying case weighing approximately 25 – 30 lbs. to and from patient's care facilities. • Travels to patient/clients’ homes and/or other facilities with varying environments (e.g., elevated buildings, walk-ups, care facilities, single/multiple family homes, presence of pets, etc.) using approved transportation options to deliver direct care to the patient. • Participates in team meetings, in-service updates, and other staff activities, as assigned. • Participates in special projects and performs other duties as assigned.
Qualifications
Licenses and Certifications:
License and current registration to practice as a registered professional nurse in New York State required CPR/BLS Certification required
Education:
Associate's Degree in Nursing from an approved program required Bachelor's Degree in Nursing from an approved program preferred
Work Experience:
Minimum of two years in a clinical background as a Registered Nurse and one-year clinical practice in specialty where appropriate (e.g., wound care, IV Therapy, etc.) required Home care experience in a licensed home care service agency or CHHA settings preferred Wound Care, CRNI or IV Certification where appropriate preferred Feeding tube/PEG tube management, Medication pre-pour/administration, Ostomy management, Urinary catheter management preferred Exceptional written and oral communication skills and strong customer service abilities to effectively interact with patients, patient family members, physicians, pharmacists and management required