Job Summary: 

• Performs the initial and ongoing assessment of patient needs and appropriateness for home care, creates and maintains an individualized goal/outcome-based care plan based on the physician’s plan of care.
• Completes accurate and current initial medication profile and maintains ongoing updates of the drug profiles in the medical record and home for assigned patients.
• Provides skilled nursing care based on the plan of care, authorizations and physician orders on assigned patients, adheres to agency policies and procedures for nursing, infection control, bio-hazardous waste management, quality improvement activities, safety and risk management practices.
• Confers with the physician in developing and revising the plan of care, reporting patient progress status, obtaining and documenting additional orders based on the initial and ongoing assessment of the patient's progress, following regulatory guidelines and policies in writing orders.
• Ensures that the plan of care includes teaching related to health maintenance and prevention of complications, safety and interventions to achieve patient outcomes.
• Provides care coordination for assigned cases by communicating patient progress, patient/family needs and status changes to the physician, appropriate team members and/or Clinical Manager.
• Makes ongoing nursing assessments, evaluates patient progress, updates the plan of care based on findings, and reports significant changes in the patient’s condition to the physician, appropriate team members and/or Clinical Manager.
• Supervises the Home Health Aide and Licensed Practical Nurse assigned to cases to ensure the plan of care is progressing towards achieving patient outcomes.
• Maintains patient caseload for case management, coordinates care activities among all disciplines on the care plan by participating actively in case conferences and discharge planning, acting as a resource and liaison with the community, multidisciplinary team and other resources to achieve patient outcomes.

Skills on Resume:

• Patient Assessment (Hard Skills)
• Care Planning (Hard Skills)
• Medication Management (Hard Skills)
• Nursing Care (Hard Skills)
• Team Communication (Soft Skills)
• Patient Education (Soft Skills)
• Care Coordination (Soft Skills)
• Staff Supervision (Soft Skills)

Job Summary:

• Maintains patient schedules based on orders and authorizations within the Medicare week, submits caregiver schedules timely and accurately, meets productivity standards demonstrating effective time management skills (i.e., contacting the patient the day before to pre-plan visit).
• Maintains daily communication with the Team Coordinator, providing updates to visit activities and changes.
• Accurately and thoroughly documents patient care observations, interventions, supply utilization and evaluations, and prepares and submits completed documentation of the home care visit within the established time parameters.
• Participates in the quality improvement and utilization review activities of the organization.
• Maintains working knowledge of and refers patients to community resources.
• Reports daily to the Clinical Manager, participates in on-call rotation.
• Exhibits good written and verbal communication.
• Attends staff meetings and in-services.
• Completes in-service on blood-borne pathogens annually, annual clinical competencies and other required activities and competencies.
• Demonstrates a high degree of commitment to professional development, customer service and quality care provision.
• Participates in staff meetings, performance improvement activities and clinical record review.
• Completes annual competencies and all required certifications.

Skills on Resume: 

• Patient Scheduling (Hard Skills)
• Time Management (Soft Skills)
• Documentation Accuracy (Hard Skills)
• Quality Improvement (Hard Skills)
• Knowledge Of Community Resources (Hard Skills)
• Communication Skills (Soft Skills)
• Professional Development (Soft Skills)
• Certification Compliance (Hard Skills)

Job Summary:

• Demonstrates knowledge and competency in performing baseline nursing skills, including assessment, wound care, catheter care and infusion. 
• Maintains clinical competencies according to agency standards.
• Completes comprehensive assessments, including OASIS items, accurate and timely manner at specific time-points as defined by regulation and agency policy.
• Develops a plan of care, in collaboration with the patient, family/caregiver and physician orders, including frequency and duration of nursing visits, specific care or treatments to be provided, appropriate goals, medications, other disciplines needed and discharge plan.
• Documents the comprehensive assessment and plan of care in the EHR and synchronizes by 10:00 AM the following day.
• Implements and provides nursing care, treatment and services according to the plan of care and accepted standards of care, including patient education and any IV or other medications required to be administered by the nurse.
• Communicates changes in patient status, patient issues and concerns and changes in orders to the Physician, Clinical Manager and Clinical Supervisor according to agency guidelines.
• Practices infection control and universal precautions for self and others in patient care activities.
• Advocate for quality patient outcomes, communicating with authorization nurses and community vendors timely.
• Maintains patient rights and dignity. 
• Assures the care of the dying patient, optimizing his/her comfort and dignity.
• Effectively establishes priorities and delegates responsibilities appropriately when supervising the LVN and the CHHA.
• Meets the productivity standards of the organization.

Skills on Resume:

• Nursing Competency (Hard Skills)
• Clinical Assessment (Hard Skills)
• Care Planning (Hard Skills)
• EHR Documentation (Hard Skills)
• Patient Education (Soft Skills)
• Communication Skills (Soft Skills)
• Infection Control (Hard Skills)
• Supervision And Delegation (Soft Skills)

Job Summary:

• Facilitates coordinated transitions from the orientation program to independence within targeted goals.
• Tracks required orientation progress and provides progress to Clinical Educators and Clinical Leaders.
• Conducts new caregivers’ competency assessment and validates competencies throughout the orientation period.
• Validates the ongoing competencies of current clinical caregivers as directed by the Clinical Educator.
• Reviews the Orientation Module content and skills with new caregivers to determine the level of understanding and re-educates.
• Provides patient-centered care and coordination of care for a patient population with diverse community-based healthcare needs to include
• Develops a comprehensive and patient-centered plan of care.
• Uses clinical evidence-based protocols and technology as identified by standard scope of practice and disease processes.
• Provides disease-specific education and self-management strategies for patients to achieve optimal patient independence.
• Follows the physician's ordered plan of care and facilitates changes to the plan of care to achieve desired patient outcomes.
• Identifies risk for acute hospitalization and proactively prevents adverse events.
• Coordinates care across the continuum as a patient advocate.

Skills on Resume:

• Orientation Coordination (Hard Skills)
• Competency Assessment (Hard Skills)
• Care Planning (Hard Skills)
• Patient Education (Soft Skills)
• Evidence-Based Practice (Hard Skills)
• Risk Management (Hard Skills)
• Care Coordination (Soft Skills)
• Patient Advocacy (Soft Skills)

Job Summary:

• Provides supervision and care plan development for service line-specific disciplines.
• Participates in interdisciplinary team meetings and case conferencing to ensure patient quality care, patient advocacy, utilization and outcomes.
• Makes recommendations related to training and skill development to the clinical education team.
• Provides comprehensive and constructive feedback for caregivers.
• Responsible for OASIS and/or review and accuracy.
• Serves in the capacity of Start of Care and or home visits when schedule allows. 
• Admits patients to service, completing appropriate clinical documentation under the Clinical Manager's direction. 
• Assesses individual status and care/instruction needed by the patient.
• Conducts supervisory visits.
• Maintains/enhances clinical practice skills by attending, participating in/conducting caregiver development/continuing education programs.
• Instructs and monitors the work of orientees in the aspects of clinical nursing relative to the assigned area, and educates nursing orientees concerning nursing policies and procedures.
• Collaborates with the Educator in planning and structuring the orientation program to meet the individual orientees' needs, and plans daily assignments for the orientees.
• Assists Educator in planning, presenting, evaluating and revising the caregiver development activities and nursing policies and procedures.

Skills on Resume:

• Supervision Skills (Soft Skills)
• Care Plan Development (Hard Skills)
• Interdisciplinary Collaboration (Soft Skills)
• Training And Development (Soft Skills)
• OASIS Documentation (Hard Skills)
• Patient Assessment (Hard Skills)
• Clinical Education (Hard Skills)
• Orientation Planning (Hard Skills)

Job Summary:

• Evaluate patients for appropriateness of admission and verify the patient’s eligibility for the Medicare home care benefit, including homebound status, at the time of initial assessment visit and comprehensive assessment.
• Assist in developing the plan of care and evaluate the outcomes of care on a regular basis, updating the patient’s plan of care.
• Identifies goals, interventions and expected outcomes, and involves the patient and/or caregivers in the plan of care and any changes in the plan depending on the ability of the patient/caregiver.
• Educate patients and family members/caregivers on the plan of care, addressing their questions and concerns.
• Provide skilled nursing care as outlined in the patient plan of care and supervise LPN and home health aides.
• Maintain up-to-date charting on each patient.
• Participate in case conferences, in-services and training.
• Preparation and knowledge within the comfort of the patient’s home.
• Perform ongoing periodic system assessment and data collection in a systematic manner, focusing on psychological, psychosocial, cultural, spiritual and cognitive status, nutrition, pain, patient/family education, family involvement and patient advocacy, patient and patient’s equipment needs.

Skills on Resume:

• Patient Evaluation (Hard Skills)
• Care Planning (Hard Skills)
• Goal Setting (Soft Skills)
• Patient Education (Soft Skills)
• Skilled Nursing (Hard Skills)
• Charting Accuracy (Hard Skills)
• Team Participation (Soft Skills)
• Systematic Assessment (Hard Skills)

Job Summary:

• Administer skilled nursing care to patients requiring professional nursing service per the physician’s orders and under the supervision of the Supervisor of Clinical Services.
• Manage each patient’s care efficiently and effectively to achieve positive patient outcomes
• Be responsible for the overall plan of care and the outcome of that care, including care delivered by other nursing staff (LPN, HHA) who will be directed/supervised by the RN.
• Teaching the family and other members of the nursing team.
• Responsible for planning, providing and coordinating quality patient care.
• Provide one-on-one care for patients in homes and may involve wound care, medication management, medication administration, hands-on care to patients, intravenous therapy lines
• Observing, monitoring patients' conditions
• Maintaining accurate records 
• Making physician recommendations

Skills on Resume:

• Skilled Nursing Care (Hard Skills)
• Care Management (Soft Skills)
• Care Supervision (Soft Skills)
• Patient And Family Teaching (Soft Skills)
• Quality Care Coordination (Hard Skills)
• Wound And Medication Care (Hard Skills)
• Patient Monitoring (Hard Skills)
• Record Keeping (Hard Skills)

Job Summary:

• Providing both Hospice and Home Health services
• Completes initial comprehensive and ongoing assessment of patient and family to determine needs
• Admissions of patients for services and development of the initial patient/family Plan of Care
• Uses health assessment data to determine nursing diagnosis
• Coordination of services with the patient, family, and hospice interdisciplinary team members
• Ongoing clinical supervision of Licensed Practical Nurses and Home Health Aids
• Reporting to the Supervisor of Clinical Services.
• Responsible for the overall plan of care and the outcome of that care, including care delivered by other nursing staff (LPN, HHA) who will be directed/supervised by the RN.
• Teaching the family and other members of the nursing team.

Skills on Resume:

• Hospice Services (Hard Skills)
• Patient Assessment (Hard Skills)
• Admissions Management (Hard Skills)
• Nursing Diagnosis (Hard Skills)
• Service Coordination (Soft Skills)
• Clinical Supervision (Soft Skills)
• Care Plan Management (Hard Skills)
• Family Teaching (Soft Skills)

Job Summary:

• Work with other healthcare professionals to create treatment plans.
• Ensures that patients stick to treatment plans.
• Monitor patients' vital signs and wound care.
• Monitor changes in behavior and progress.
• Monitors and administers medication.
• Communicates with the referring physician.
• Participates in professional development activities and maintains professional affiliations.
• Triages patient phone calls and documents relevant information in the patient’s chart

Skills on Resume:

• Treatment Planning (Hard Skills)
• Patient Compliance (Soft Skills)
• Vital Signs Monitoring (Hard Skills)
• Behavior Monitoring (Hard Skills)
• Medication Administration (Hard Skills)
• Physician Communication (Soft Skills)
• Professional Development (Soft Skills)
• Patient Triage (Hard Skills)

Job Summary:

• Develop a plan of care under the direction of the client’s physician and in collaboration with the client, their family, and/or the primary caregivers upon admission.
• Coordinates the client’s care plan through interdisciplinary communication and case conferences. 
• Advises other disciplines on discharges on a timely basis.
• Provides ongoing assessment of the client’s clinical, functional, and emotional status to identify problems and/or progress toward desired goals.
• Prepares home health clinical notes and updates the case manager and primary physician.
• Completes, maintains and submits accurate and relevant hospice clinical notes regarding the patient’s condition and care given. 
• Records pain/symptoms management changes /outcomes.
• Communicates all pertinent information and any interventions to the physician.

Skills on Resume:

• Care Planning (Hard Skills)
• Interdisciplinary Coordination (Soft Skills)
• Discharge Planning (Hard Skills)
• Clinical Assessment (Hard Skills)
• Clinical Documentation (Hard Skills)
• Pain Management (Hard Skills)
• Communication Skills (Soft Skills)
• Case Updates (Hard Skills)

Job Summary:

• Provides those services requiring nursing skills in accordance with the plan of treatment or plan of care.
• Demonstrating collaboration with and responsibility
• Adheres to all payroll, billing and documentation policies and procedures
• Participates in the agency’s activities, In-Service, QA/UR Committee 
• On-Call Rotation Personal Growth
• Provide nursing services in patients’ homes, expecting 5-6 visits per day, serving a population of elderly and adult patients
• Handling wound care, medication administration, and some case management
• Attend weekly case conferences (currently being held virtually)

Skills on Resume:

• Nursing Skills (Hard Skills)
• Collaboration (Soft Skills)
• Billing Compliance (Hard Skills)
• Quality Assurance Participation (Hard Skills)
• On-Call Availability (Soft Skills)
• Home Nursing Care (Hard Skills)
• Wound Care (Hard Skills)
• Case Management (Hard Skills)

Job Summary:

• Provide high-quality care in the home by developing a plan of care in collaboration with the patient/caregiver, the patient's physicians, and other care disciplines
• Follow disease management processes and established protocols to ensure the goals determined in the plan of care are met
• Educate patients and caregivers on the management of their illness to encourage compliance and prevent rehospitalizations
• Reassess patients to determine plan of care needs have changed, or it may be appropriate to recommend other disciplines, advanced care planning, or hospice
• Document in Homecare Homebase (HCHB), Residentials EMR, through a company-provided tablet
• Manage and provide primary patient care to a select group of patients
• Assure quality and maintain open communication with patients
• Present the patient at interdisciplinary team meetings
• Collaborate with team members to ensure patient care delivery needs are met
• Interact with any and all members of the care group, both internal and external to the organization

Skills on Resume:

• Care Planning (Hard Skills)
• Disease Management (Hard Skills)
• Patient Education (Soft Skills)
• Patient Reassessment (Hard Skills)
• Electronic Documentation (Hard Skills)
• Primary Patient Care (Hard Skills)
• Interdisciplinary Communication (Soft Skills)
• Team Collaboration (Soft Skills)

Job Summary:

• Complete a thorough nursing assessment on admission and with each skilled nurse visit.
• Provide services or treatments requiring substantial and specialized nursing skills according to the written patient care plan and the signed plan of treatment.
• Supervise and guide care provided by LPN and Home Health Aide.
• Demonstrate knowledge of home health regulatory standards and policies of the agency.
• Establish a plan of care that is realistic and has measurable goals.
• Provide a full range of nursing care, including assessment, treatment planning and hands-on nursing care in an interdisciplinary environment consistent with the position's qualifications, professional practices and ethical standards.
• Demonstrate accountability for and contribution to care planning development, quality improvement, problem-solving and productivity enhancement in a flexible interdisciplinary fashion.
• Prepare patients for examinations, testing and procedures.
• Obtain vital signs, height and weight and record medical history.
• Prepare clinical and progress notes for the patient’s clinical record.

Skills on Resume:

• Nursing Assessment (Hard Skills)
• Specialized Nursing (Hard Skills)
• Staff Supervision (Soft Skills)
• Regulatory Knowledge (Hard Skills)
• Care Planning (Hard Skills)
• Interdisciplinary Nursing (Hard Skills)
• Quality Improvement (Soft Skills)
• Clinical Documentation (Hard Skills)

Job Summary:

• Make initial evaluations and regularly reevaluate the patient's nursing needs and update the plan of care.
• Provides skilled nursing services to include catheter care, wound care, disease management teaching, and medication management.
• Works closely with the patient/family/caregivers and other members of the interdisciplinary team
• Supervise, delegate, teach and train aspects of patient care to unlicensed individuals
• Meet the productivity expectations of the agency.
• Demonstrate and provide comprehensive documentation of services rendered.
• Maintenance and Port access and de-access (Infusaports).
• Insertion and maintenance peripheral line.
• Provide excellent customer service to the patient and family
• Documents nursing assessments and patient teaching in the patient chart.
• Responsibility for patient mix as acute med surg, neuro, cardio-pulmonary, wound care patients/wound vacs, IV infusion (antibiotics/TPN), pleurx catheters.

Skills on Resume:

• Patient Evaluation (Hard Skills)
• Skilled Nursing (Hard Skills)
• Team Collaboration (Soft Skills)
• Supervision And Training (Soft Skills)
• Documentation (Hard Skills)
• Infusaport Maintenance (Hard Skills)
• Peripheral Line Insertion (Hard Skills)
• Customer Service (Soft Skills)