Position : RN-Home Health
Home Care Case Manages maintain a case load of home care clients through assessment, plan of care, coordination and implementation, of evidence based care for each client, with the support of an interdisciplinary care team.
This includes but is not limited to: appropriate treatment intervention, evaluation of outcomes, and utilization of services to ensure that patient care needs are met. Will participate in on-call and weekend rotation.
Develop a plan of care under the direction of client’s physician and in collaboration with the client, their family and/or the primary care givers upon admission. Periodically reviews the client care plan and re-certifies the client care plan as appropriate.
Coordinates the client’s care plan through interdisciplinary communication and case conferences, as appropriate. Advises other disciplines of discharges in a timely basis.
Provides ongoing assessment of the client’s clinical, functional, and emotional status to identify problems and/or progress toward desired goals.
Initiates and applies interdisciplinary and therapeutic interventions using appropriate technique; obtains appropriate MD approval. Needs time frame – immediately, within 24 hours
Supervises ancillary personnel (Home Health Aides and Licensed Practical Nurses) and delegates responsibilities when required. Establishes a care plan for paraprofessional services and revises as needed according to agency policy.
Completes and submits accurate and relevant clinical notes and other required documentation in a timely manner in accordance with expected agency standards, state and federal regulatory compliance i.e., admission papers and OASIS; clinical notes; day sheets; status change; resumption of care; verbal orders/memos; payer source documentation, including management of authorizations; discharge.
Completes all clinical documentation on the laptop, in the home when appropriate and in a timely fashion. Transmits all information at least twice a day.