Reports To: Director of Intake and Service Development

Position Summary: To manage and facilitate the transition of patients from an on-site unit of a hospital or skilled nursing facility to the home.

Schedule: 3 days/week 7.5/hr shifts

Duties and Responsibilities:
Evaluates patients referred for home care/hospice care and appropriately identifies:
Skilled need. Patient safety. Homebound status. Patients/Familys ability to provide appropriate care. Patients request for home care/hospice care. Needs for other services (including PT/OT/ST/Aide/MSW/Telemonitoring/NP).
Consults with physicians, nurses, social workers and other disciplines while establishing a coordinated home care plan prior to discharge. Obtains complete and accurate physicians orders for all patients who require care, with specific orders for wound care, diabetic management, medications, and/or foley care required Appropriately assesses patients for DME, supplies, and/or lab work and ensures arrangement for same. Notifies agency of patient acceptance of home care/hospice, provides complete and accurate intake data, essential background information, care plan and signed medical orders when possible. Provides feedback to hospital personnel on referrals made for home care/ Confers with agency personnel on patient progress and on-going evaluation and provides consultation on discharge from home care or re-admission to the hospital or another facility. Serves as a liaison between hospital and home health agency staff regarding patients, policies and staff. Obtains required Face to Face Documentation, Face to Face Encounter Note, and Discharge Documents. Ensures appropriate physician oversight of patient Care as per VNSHS and the Federal Guidelines by verifying the community MD. Serves as a resource to hospital staff on community resources and home care/hospice issues and practices. Assists with the exploration, identification and evaluation of present and potential needs and resources in relation to the community health program. Identifies the availability of community resources and utilizes those that best meet the needs of the patient. Offers in-service to hospital staff regarding home care/hospice Identifies potential referral sources in the community and assists with increasing agency visibility Demonstrates organizational skills in caseload management. Has the ability to prioritize caseload; utilizes time efficiently. Demonstrates effective communication skills with other agency team members/departments, i.e. leaves report if covering or sharing caseload at a facility. Also maintains communication with Intake, Billing, and Area/Hospice Assists in the orientation of new staff and works with nursing students, as requested. Seeks supervisory input regarding appropriateness of referrals when concerns or questions arise. Demonstrates flexibility in covering other facilities as a coordinator when requested. Provides daily reports to supervisor regarding caseload at designated sites. Attends mandatory meetings, inservices, and maintains agency standard for annual inservice hours. Employee adheres to all applicable federal, state, local laws and regulations. Employee is required to do 3 hours of inservices a year. Other duties as assigned.

Qualifications:
License and current registration to practice as a registered professional nurse in New York State.B. S. Degree from an accredited program in nursing preferred.One year nursing experience in acute care setting with additional experience in a certified home health agency.Knowledge of community health nursing principles and practices.Knowledge of the types of care and treatment available to patients in hospitals and institutions and the methods by which this care may be extended into the home.Knowledge of programs available through the Home Health Agency, Hospice and other community resources.Knowledge of current developments, literature and sources of information in the field of community health nursing. Attends mandatory meetings and maintains agency standard for yearly inservice.Skill in the application of professional nursing techniques and practices.Ability to interpret home health agency policies to hospital personnel.Establish and maintain effective working relationships with hospital personnel and other agencies and individuals associated with home health care.Interact with patients and their families, explaining scope of program and services.