RN, Team Lead-Home Health (FT, Days)

Job Summary:
To ensure coordination of care and services provided to all patients receiving home care services in the Home Health Program.  Key functions are to develop a coordinated admission plan of care for patients referred; facilitate coordination of disciplines and services; use problem-solving and critical thinking skills to facilitate, coordinate, and execute effective, timely responses to clinical problems as they arise for patients and home care clinicians; and facilitate transitions across the continuum of healthcare settings for all home care patients.

Essential Responsibilities:

• Referral and Admissions to Home Care: Receives and evaluates appropriateness of the home health referral in collaboration with other team members (care team members, supervisor, scheduler, care (discharge) coordinators, long-term care team, expanded care, physicians, clinic social workers, and others as needed). Ensures timely admission based on assessment. Assess clinical implications of services ordered, patient/caregiver ability to manage self-care, requirements for clinical monitoring, patient stability, patient behavior that could impact a safe plan of care, and other factors that could impact safety and efficacy of admission care plan. Coordinate appropriate services and interventions by obtaining appropriate initial physician orders (e.g. wound care; wound VAC, medications, etc). Participate in the development and coordination of a comprehensive admission plan of care that incorporates an understanding of patient-specific benefits and eligibility requirements in collaboration with care team, outpatient resources, and referring physician. Assure that appropriate supplies and equipment needed to provide initial services are available (e.g. wound supplies, wound VAC, DME, enteral pumps, glucometers, medications, etc) to meet patient needs. Make recommendations to modify the plan of care to expedite a safe transition of care, reduce risks, and enhance patient outcomes. Identify and communicate start of service to patient/caregiver and home care scheduling staff based on physician orders and patient care needs. Discusses and collaborates with referral source, home care team members, physician, discharge coordinator, and supervisor regarding complex discharges, unsafe discharge plans, and inappropriate referrals. Assists in identifying and coordinating alternative options to current care needs, which may include on-site or telephone conference with healthcare team members and patient/family/caregivers. Advocate for the patient and family, as well as the healthcare system to optimize utilization of resources.  This includes acting on behalf of the member to ensure they are informed of their financial obligations and understand their appeal rights. Coordinates referrals out to contract and non-contract providers for members that require home care services that can not be provided by agency staff within the Portland/Vancouver service area. Develop and maintain expert level of knowledge and skills related to agency policy, state practice acts, applicable state and federal regulations, utilization management, and qualifications for home care services.


• Optimizes the patients home care plan by providing: Telephone Advice/Problem-solving for patients/caregivers. Follow up to after hours advice calls. Resource, support, and advice for home care staff. Physician communication and support. Facilitates scheduling of follow up visits and procedures related to advice calls. Oversees the day to day staffing and patient schedules and problem-solves staffing challenges to meet patient needs, within staffing rules. Supply and DME ordering. Assistance with paneling patients with physicians. Facilitates Care Conferences (Case Conferences, Complex Discharges, etc). Coordinates care with Home Phlebotomy. Conducts Medication Reconciliation for Therapy only cases. Reviews and approves Home Health Aide Care Plans for Therapy only cases.


• Coordinate, expedite, and track referrals and transitions across care settings (e.g. home phlebotomy referrals, wound program referrals, transfers to inpatient, transfers to ICF/SNF, and across home care programs). Acts as Kaiser Permanente ambassador to provide member information to care facilities (SNF/ICF, assisted living, adult foster care home, and residential care facilities) and problem-solve/facilitate any issues which present barriers to safe transfers and the provision of quality care (e.g.  Special equipment needs, symptom/behavior management, financial assessment and plan, clinical instability, and complex care needs.


• Provide education and program development functions: Ensures systematic and on-going contact with hospital staff and other Kaiser Permanente Departments (e.g. GLTC, DME, Hospital Care Coordinators, Clinic Social Workers, Clinic case Managers, Pharmacy, Home Infusion Program, Membership Services, etc) to share information and ensure safe transitions of care. Provides education to staff to expedite safe transitions of patients across care settings. Participates in orientation of staff to the department. Ensure appropriate and timely care to patients through collaboration with inpatient staff, CCS home care staff, and outside resource staff. Provides mentoring and coaching, and input into staff evaluations and documentation of performance problems to Clinical Supervisor. Participates in professional committees and task forces as needed/requested. Ensure regulatory and compliance standards are met in collaboration with others in the inter-disciplinary health care team. Participates in quality and utilization management activities (e.g. Chart audits). Participates in continuing education to incorporate and maintain up to date knowledge and best practices in home health.


• Conducts patient home visits as required to assist the program in meeting patient needs.


• Cross Home Health program coverage as needed. Participate in program call duty as needed. Other duties as assigned.