Job Summary:
Manages patient discharges with patient, patient families, and health care team. Develops home care plan for patient's post-hospital needs. Serves as resource and liaison with hospitals, skilled nursing homes, board and care homes, outpatient discharge planning services and physician offices. Arranges for home delivery of medical equipment and supplies. Assists is processing patient discharges. Provides support to department leadership for recruitment and selection of new staff, delivering training sessions, staff scheduling and performance management. Supervises and directs the activities of various levels of assigned personnel utilizing both professional and supervisory discretion and independent judgement.
Job Requirements:
Education and Work Experience:
- Bachelor's Degree in nursing or equivalent combination of education/related experience: Required
- Master's Degree: Preferred
- Five years' home care nursing experience: Preferred
- One year's leadership experience: Preferred
- One year's hospital case management (including discharge planning) experience: Preferred
Licenses/Certifications:
- Registered Nurse (RN) or Physical Therapist (PT) licensure in the state of practice: Required
- Public Health Nurse licensure in state of practice: Preferred
- Cardiopulmonary Resuscitation (CPR) certification or Basic Life Support (BLS) certification from approved vendor per AH policy: Preferred
- Valid Driver's License (DL) and must be at least 21 years of age or older: Required
- Physical Therapist (PT) or Registered Nurse (RN): Required
Essential Functions:
- Participates in discharge planning discussions with patient, patient care team and patient families. Consults with other health care personnel within the hospital and community agencies to develop continuity of care plan for patients being discharged from hospital. Makes referrals and provides information to home care service agencies.
- Conducts daily rounds on nursing units to review home care discharge plan needs and complete progress notes on patient charts. Monitors admissions on a daily basis to evaluate and identify a patient's need for assistance in discharge planning as it relates to home care. Meets clinical supervisor on a regular basis to review patient referrals.
- Compiles monthly statistics. Provides information for field charts for each discipline with medical record information for Home Health and hospice standards of care. Reports patient assessment and evaluation to physician/Team Leader/Manager of Clinical Services. Assists with orientation of new employees and/or registry personnel. Provides in-service education to hospital and medical staff.
- Assesses Home Health and Hospice referrals and continuation of services from community for intake support. Assists and advises in developing and implementing marketing, business and strategic plans for home care program. Evaluates need for medical supplies and equipment required for patient's home care. Orders and arranges delivery for patient post-hospital equipment and supply needs.
- Participates in recruitment and selection processes for department staff. Identifies staff training needs and arranges in-service sessions as needed. Trains new employees job duties and assignments. Addresses complaints made by supervised staff including training needs, work assignments and overtime scheduling. Completes periodic evaluations of personnel supervised. Coaches and counsels staff not meeting performance expectations issuing formal oral and written reprimands. Attends appropriate hospital committees meetings.
- Performs other job-related duties as assigned.
