As part of a person-centered care model, this role will provide skilled nursing care to clients in home and community-based settings ensuring the delivery of outcome based, high quality, cost-effective care. This role will collaborate with all team members to achieve exceptional outcomes. Maintains a client record utilizing the Agency's standard for documentation. Makes follow-up visit to provide skilled care to assess disease progress and evaluates response to treatment; provides support to patient/family utilizing teaching principles to promote and restore health and prevent disease and disability; coordinates care with providers. Carries out the plan of care. Teaches patients and reinforces client/caregiver teaching and education. Refers, collaborates, and coordinates all client care services. Consults with physician regarding client needs and plan of care. Communicates/conferences with Nurse Care Coordinator and all involved in the patient's care. Directs LPNs in carrying out the established plan of care. Directs Home Care Aides and supervises plan of care. Refers client/family to other community resources as needed. Attends and participates in in-service education program. Qualifications: Minimum Requirements: Education: Graduate of an Associate's Degree or diploma program in nursing Experience: One year nursing experience or one year nursing experience in a specialty Licensure: Registered nurse with a license to practice in the state of CT Preferred: Education: Graduate of NLN approved BSN program Experience: Medical/surgery or home care experience