Accepts and refers patients appropriate for skilled home care services. Under supervision, upon referral from the Case Management team, assess patient’s needs for Skilled Home Care services. Formulates and implements a comprehensive Home Care plan, refers patient to Home Care agency of their choice. Works collaboratively with Physicians, Nursing Management, Case Management team, and other ancillary departments to assure patients reach quality outcomes.
1. Functions as a RN Home Care Discharge Planner between SIUH and all Home Care Agencies.
2. Receives from Case Management team referrals for Skilled Home Care services.
3. Evaluates/assesses patients for appropriateness for Skilled Home Care services which includes an in-depth assessment of the patients’ needs, including coordination of activities with family, informal support and other community resources.
4. Identifies patients enrolled in the Disease Management Program (CHF, AMI and Pneumonia/COPD) and highlight such referrals to the agencies.
5. On an ongoing basis during a patients’ hospital stay, plans for the skilled home care needs of patients in a timely manner to ensure patient’s expeditious movement to the next level of care.
6. Discusses with Case Management team and any/all members of the interdisciplinary team outcome of evaluation and makes any recommendations when appropriate.
7. Makes referral to the Home Health agency of patient’s choice.
8. Communicates to the Case Management team outcome of referral and start date for skilled home care services.
9. Obtains any necessary authorization and maintain working knowledge of third-party reimbursement guidelines and regulatory standards.
10. Collaborates with Case Management team, Disease Management team and any members of the healthcare team on transition of patient’s care from acute care to home with services. Ensures patients are prepared for discharge and understand the post discharge plan of care.
11. Performs related duties as required.
Frequent – Ability to move throughout patient care units and all other areas of the hospital/sites. Ability to read medical records and patient charts frequently.
Graduate from an accredited School of Nursing. Bachelor’s Degree in Nursing, preferred.
- Current license to practice as a Registered Professional Nurse in New York State.
- Minimum one (1) year acute hospital clinical nursing experience and/or Home Care services, required. Minimum (1) one year Community Health experience, required. Discharge planning experience strongly preferred.
- Knowledge of Case Management process, preferred.
- Ability to verbally communicate effectively.