Home Health RN Field Case Manager

POSITION:          Home Health RN Field Case Manager

MAIN FUNCTION (Job Summary):

               A qualified Registered Nurse (RN) administers skilled nursing care to patients on an intermittent basis in their place of residence.  This is performed in accordance with physician orders and plan of care under the direction of the Clinical Managers.  Services are furnished in accordance with Wooster Community Hospital Home Health Services policies, Wooster Community Hospital policies, and Ohio Board of Nursing Scope of Practice regulations.

RESPONSIBLE TO (Job Relationship):

• Supervised by:   Director/Administrator, Clinical Managers
• Workers Supervised:  LPNs, Home Health Aides

REPORTS TO (Reporting Responsibilities):

• Director/Administrator, Clinical Managers

MUST HAVE REQUIREMENTS (Job Qualifications, Experience, Education/Training, Professional License):

• Bachelor's Degree
• Current State of Ohio driver’s license
• Current automobile insurance
• Professional licensure: State of Ohio RN
• American Heart Association Basic Life Support (BLS) card current
• Acceptance of philosophy and goals of Wooster Community Hospital and Home Health Services department
• Ability to exercise initiative and independent judgment
• Demonstrated autonomy, accountability, and organization skills in performing/completing job responsibilities
• Excellent communication skills
• Knowledge and ability to apply nursing process
• Knowledge and ability to apply community health principles and practices
• Demonstrated ability to direct professional personnel
• Ability to work as a team member

PREFERRED ATTRIBUTES (Experience, Education/Training):

• Home care experience
• Computer skills (keyboard, computer applications)
• Minimum of two (2) years nursing experience, preferred

WORKING ENVIRONMENT:

• Works indoors in the department office.
• Works in patient homes.  Travels to/from patient homes.

OTHER REQUIREMENTS (including Risk Exposure and Lifting Requirements):  Employees in this position may be:

• Exposed to blood, body fluids and/or airborne pathogens.
• Required to don personal protective equipment, per Standard Precautions, and as applicable to the patient’s disease process.
• Able to participate in physical activity.
• Able to work for extended periods of time while standing and being involved in physical activity.
• Able to push, pull, lift, carry, turn, crouch, stand, and bend on a regular basis, as necessary to perform patient care and job duties.
• Required to take ‘On Call’ work shifts.
• Subject to STHR (short term hour reduction) according to scheduling policies.

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POSTION EXPECTATIONS (Responsibilities & Job Duties):

Leadership

• Accepts and responds to change productively, while maintaining a positive attitude
• Demonstrates conflict resolution skills
• Reports actual and near-miss adverse events to Director/Administrator, or designee, in a timely manner
• Speaks positively of the department to customers, referral sources, and community healthcare partners

Communication

• Maintains awareness of verbal and non-verbal communication during interactions with coworkers, patients, caregivers, health care providers, and health care vendors
• Maintains patient confidentiality in all communication interactions: written, verbal, electronic, and digital
• Collaborates and communicates effectively with all interdisciplinary team members (handoff communication, interdisciplinary care coordination)
• Reports critical information to physician and other team members, as indicated
• Utilizes chain of command to handle issues
• Participates in care coordination communication(s), including handoff communication
• Demonstrates basic ability to initiate and manage crucial conversations
• Utilizes AIDET (Acknowledge, Introduce, Duration, Expectations, Thank You) strategies to foster positive communication among all interdisciplinary team members, coworkers, health care providers, health care vendors, and students

Operations

• Follows all Infection Prevention strategies, including hand hygiene
• Completes and submits OASIS assessments, reassessments [ recertification, follow-up], transfers, resumptions of care, discharges, and significant change of condition as defined by department documentation guidelines
• Assumes responsibility for the ongoing interdisciplinary assessment and development of the individualized plan of care in partnership with the patient, patient representative [if any], caregiver(s)
  1. Determines the amount and type of nursing needed by each individual patient, in conjunction with the interdisciplinary team members, physician, patient, caregiver, and patient representative
  2. Initiates the plan of care.
  3. Initiates appropriate preventive and rehabilitative nursing procedures
• Coordinates services (field case management)
  1. Refers to Physical Therapist, Speech Language pathologist, Occupational Therapist, Medical Social Worker, and Home Health Aide those patients requiring their specialized skills
  2. Communicates to interdisciplinary team members patient’s care needs, teaching to be completed, plan of care revisions, and new physician orders.
• Conducts initial evaluation visit and regularly reevaluates the patient’s nursing needs.
  1. Revises patient individualized plan of care, as necessary
• Conducts supervisory visits.  Provides feedback to LPN and/or HHA, as necessary
• Accurately performs a multisystem patient assessment
• Observes signs and symptoms reported by the patient and/or caregiver
• Observes patient’s response to treatments, education, and medications
• Provides patient care/procedures (services) ordered by the physician, as indicated in the plan of care (485) and patient individualized goals & interventions, according to department & organization procedures, as assigned
  1. Provides those services requiring substantial specialized nursing skills
  2. Gives total patient care, as needed
• Provides patient and caregiver education (teaching), utilizing patient teaching resources approved by Wooster Community Hospital and/or Home Health Services leadership
• Assess patient and caregiver knowledge of teaching utilizing teach-back and return demonstration strategies
• Processes & documents physician orders.  
• Completes certification/recertification orders and transfer/discharge summaries.
• Accurately documents assessments, interventions, response to interventions, response to teaching, and progress towards goals (outcomes) in the medical record
• Communicates (reports) with interdisciplinary team members, including the physician(s), the patient’s progress towards goals, response to treatments, change in condition [if any], new signs & symptoms for the patient, and/or revisions in plan of care
• Collaborates with Clinical Managers and other disciplines to prepare patient for discharge once patient-specific, individualized, goals are met
• Leads/participates in the interdisciplinary coordination of care conversations/care planning for patients assigned to their care
• Notifies the Clinical Manager and/or Scheduler, or designee, of patient visit schedule changes in a timely manner
• Competently performs skills/job responsibilities listed on standard work/skills list for job position.
• Coordinates work to achieve maximum productivity.  Able to multitask and prioritize workload.  Work habits are consistently adjusted to accommodate multiple responsibilities.  Responsibilities are prioritized and completed in a timely manner.
• Demonstrates reasonable and rational judgment in decision making.
• Maintains equipment and supplies in proper working order.  Reports issues to Clinical Manager and/or Director/Administrator.

Customer Service

• Displays positive attitude.  Treats others with honesty and respect.  Speaks positively in all customer interactions internal and external.
• Uses AIDET (Acknowledge, Introduce, Duration, Explanation, Thank You) to:
  1. Optimize the patient’s experience by reducing the patient and caregiver’s anxiety
  2. Increase patient compliance
  3. Develop positive relationships with other employees, health care providers, and health care vendors
• Assesses customer satisfaction during interactions.  
• Maintains positive working relationships with coworkers, referral sources, and healthcare providers
• Uses appropriate chain of command for unresolved issues or problems.
• Uses face-to-face resolutions (crucial conversations) to intervene with patients, caregivers, health care providers, vendors, students, and/or coworkers in situations where customer needs have not been met to determine a positive, mutually agreeable resolution.

Staff Development / Personal Growth

• Attends department meetings, educational activities, and inservices
• Supervises and teaches other nursing personnel
• Demonstrates initiative and responsibility to develop personal and professional goals.
• Demonstrates professional growth by maintaining awareness of changes in home care industry.
• Demonstrates professional growth by maintaining awareness of applicable professional best practices.
• Accepts feedback as opportunity for growth.
• Demonstrates knowledge and understanding of new policies & procedures, practices/standard work, and initiatives.  Obtains this knowledge via attending staff meetings, reading paper & electronic communications, plus completing required hospital & home health education.
• Maintains professional license.

Performance Improvement (QAPI; Quality Assessment & Performance Improvement Program)

• Maintains awareness of CMS conditions of participation and accreditation standards.
• Reviews home care patient satisfaction survey, value based purchasing, and 5 Star Rating data, as distributed by home health leadership.
• Participates in QAPI projects: identifies processes to be improved, communicates ideas to home health leadership, assists in process flowcharting & brainstorming, collects data [if assigned], attends education on new processes, and incorporates new processes in job performance.
• Participates in data collection and chart audit(s), as assigned
• Embraces change in the home care practice environment so as to optimize patient outcomes while maintaining financial stability

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AGE SPECIFIC COMPETENCY: Adults and Geriatrics (18 years and older)

• Identifies physical, social, cultural, and emotional barriers plus physical limitations throughout episode of care
• Integrates patient’s barriers and limitations in individualized plan of care
• Teaches patient about one topic/item at a time
• Repeats instructions several times
• Speaks slowly and distinctly when talking to the patient

 

Employee Attestation of Receipt and Understanding of Job Description:

• I have read the above job description and fully understand the conditions specified in this document.  
• I will perform these duties to the best of my knowledge and ability.
• I will adhere to Wooster Community Hospital policies & procedures, Wooster Community Hospital Home Health Services policies & procedures, Home Health Scheduling Guidelines, and Wooster Community Hospital Employee Handbook.

 

Employee Signature: ______________________________________________ Date: __________

5- 8 hour shifts,
On call 1 night per week and 1 weekend every 6-8 weeks
40