Coordinates and provides high quality multidisciplinary health services for patients in the Region/Program consistent with Agency philosophy, policy, goals and objectives, and Standards of Nursing Practice. Works under moderate supervision.
- Assesses the physical, social and psychological needs and living conditions of the patient through professional knowledge and skills of observation, interviewing and physical examination.
- Travels to patients’ 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.
- Establishes/implements/revises a plan of care with input from appropriate multidisciplinary health team members (i.e., physician, OT, PT, SW, SLP, family members) based on goals mutually acceptable to the patient and significant others.
- Implements the care plan by ongoing assessment, planning, coordination, counseling, teaching and supervision.
- Oversees/supervises the care being provided to the patient by Licensed Practical Nurses and paraprofessionals through regular home visits (every two weeks or sooner), which are in compliance with regulatory requirements. Assesses the patient’s condition and updates the plan of treatment, as needed.
- Provides nursing care in accordance with Agency policies, practices, procedures and Standards of Nursing Practice, which may require standing, stooping, sitting, crouching, bending and stretching to deliver patient care. .
- Acts as the coordinator of care for the multidisciplinary team by providing care to patients collaborating/making/confirming referrals to other disciplines /community agencies and ordering supplies/services and ensuring they are delivered as needed. Consults patient’s MD and follows-up on problematic situations affecting care such as abnormal clinical findings or medication discrepancies.
- Transports and utilizes required medical equipment and supplies using VNSNY designated/supplied carrying case weighing approximately 25 – 30 lbs. to and from patient homes/care facilities, VNSNY offices and other locations.
- Documents content and process of all services provided in accordance with government regulations/requirements, Agency policies, practices, and procedures.
- Monitors the effect of the care plan on the patient/family health status and informs physician and other team members of changes in the client's needs
- Assists patients with activities of daily living, which may require positioning, moving, transferring and lifting patients of varying weights and physical conditions, with and without assistance and as appropriate, from family members and/or paraprofessionals.
- Consults with and educates the client and family regarding the disease process, self-care techniques and prevention strategies.
- Appraises care provided and revises the goals and approaches to patient care, as needed.
- Initiates and maintains written (including clinical and progress notes) and verbal communications with team members and management to assure optimal patient care.
- Plans and executes the patient’s safe discharge from service. Ensures that physician’s orders, discharge summary and communication to team members, patient and family members adhere to Agency and regulatory requirements.
- Performs established work procedures in relation to Region Program workflow.
- Understands/interprets/implements the Agency standard reimbursement policy and determines the billing source for patient care. Consults with management on complex/unique reimbursement cases.
- Manages and coordinates all aspects of a caseload, as assigned.
- Maintains productivity sufficient to meet Agency goals.
- Participates in the orientation of selected staff through ‘buddy system’ field observation of staff and feedback to appropriate staff involved in orientation process.
- Participates in selected student programs by providing guidance, training and mentoring to students.
- Assumes responsibility for personal professional growth through attendance at in-services, training, continued formal education and select journal readership.
- Performs other related duties and participates in special project, as assigned.
Licensure: License and current registration to practice as a registered professional nurse in New York State, required. Valid driver's license or NYS Non-Driver photo ID card, may be required as determined by operational/regional needs.
Education: Bachelor’s Degree in Nursing from an approved program, required.
Experience: Minimum of one year of clinical nursing experience including at least six months of Hospice, or Med/Surg or ICU or Emergency Dep’t or Home care, Palliative Care, Oncology or Long Term Care experience, required. Bilingual skills may be required, as determined by operational needs. Demonstrated computer skills may be required based on operational needs.