- Assesses the physical, social and psychological needs and environmental conditions of the patient through professional knowledge, skills of observation, interviewing, and physical examination to develop a plan of care.
- Understands, interprets, and implements reimbursement protocols; determines the billing source for patient care. Consults with management on complex/unique reimbursement cases.
- Acts as the coordinator of care for the multidisciplinary team by providing and managing the care needs of patients which includes /making/confirming referrals to other disciplines/community agencies and ordering supplies/services and ensuring they are delivered as needed. Communicates and consults with patient's MD and follows-up on problematic situations affecting care such as abnormal clinical findings, medication discrepancies, or other factors that impact patient's ability to comply with the plan of care. Manages and coordinates all aspects of assigned caseload.
- Establishes, implements, and revises a plan of care with input from appropriate multidisciplinary health team members (i.e., physician, OT, PT, SW, SLP, family members, caregivers, HHAs, etc.) based on goals mutually acceptable to the patient and significant others. Ensures that services follow the plan of care by ongoing assessment, planning, coordination, counseling, teaching and supervision of the delivery of care to meet the needs of the patient.
- Oversees/supervises the care provided to the patient by Licensed Practical Nurses and Paraprofessionals through regular home visits in compliance with regulatory and VNSNY requirements. Assesses the patient's condition, monitors the effect of the care plans on the patient/family health status, informs physician and other team members of changes in the client's needs and updates the plan of treatment, as needed.
- Documents content and process of all services provided in accordance with government regulations/requirements, and VNSNY policies, practices, and procedures. Initiates and maintains written (including clinical and progress notes) and verbal communications with team members and management to assure optimal patient care.
- Assists patiets 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
- Manages, plans, coordinates 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 VNSNY and regulatory requirements.
- 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.
- Provides nursing care in accordance with VNSNY 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 supplies using VNSNY designated/supplied carrying case weighing approximately 25 – 30 lbs. to and from patient homes/care facilities
- 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.
- Follows work procedures in relation to established workflows.
- Maintains productivity sufficient to meet VNSNY goals.
- 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.
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