Home Health Registered Nurse Mentor

The home health registered nurse Mentor uses the nursing process (assesses, plans,
implements, evaluates) to provide patient care in the home setting and to provide field clinical training to new nursing hires to Home Health. Provides
individualized patient care for patients in all developmental stages throughout the life
span including:
Adult - 18-72 years, Geriatric - 72 + years, according to
established policies, procedures, guidelines and nursing standards of care. Provides additional precepting oversight to new hires. This position is responsible for the care and case management of patients in all stages of life in their homes based on the nurse's experience and competency evaluation.

* PRIMARY JOB DUTIES
* 1. Assesses, interprets, plans, implements and evaluates patients according to the patient's age and diagnosis.
2. Effectively and efficiently manages the care of a caseload of patients and coordinates care with a multidisciplinary team.
3. Appropriately communicates information in accordance with agency policies and procedures and discipline specific guidelines.
4. Provides practical clinical experience and guidance to field clinicians to include orientation of new clinicians
5. Contributes to program effectiveness.
6. Organizes and performs work effectively and efficiently.
7. Maintains and adjusts schedule to enhance agency performance.
8. Demonstrates a daily commitment to the values of the agency.
9. Demonstrates positive interpersonal relations in dealing with all members of the agency.
10. Maintains and promotes customer satisfaction.
11. Effectively demonstrates the mission, vision, and values of the Agency on a
daily basis.

* 1.0 30% QUALITY OF WORK:
* 1.1 7 %
Utilizing all aspects of the Nursing Process (assessment, planning, implementation, evaluation) with appropriate skill to effectively manage the Plan of Care for each patient as evidenced by:

* Providing nursing intervention based on physiological needs and clinical assessment appropriate for the patient's age and developmental stage.

* Providing and/or facilitating education according to the Plan of Care and within the level of understanding and developmental age for both the patient and his/her family.

* Providing developmental interventions appropriate to patient's age and clinical status.

* In collaboration with the patient/family and the physician, the nurse performs and documents a thorough, timely initial assessment to determine the eligibility for home care and to identify needs and problems.

* Reassesses the patient at the minimum of every 60-62 days or when the patient demonstrates a significant change in clinical status, support system or care environment. Reviews and accurately updates the overall plan of care (CMS 485) at least every 60-62 days, incorporating all pertinent changes in the physician summary letter, concisely summarizes the significant facts of care and the progress toward achieving goals.

* Obtains physician orders and utilizes data collected during the admission assessment; agency teaching guidelines and appropriate nursing skills to implement and follow an established plan of care. Evaluate and revise the nursing and aide plans of care, when there are changes in the patient's condition, psychosocial status, and home environment; when no progress toward stated goals is evident and when there is a change in physician orders.
1.2 6 %
Effectively and efficiently manages the care of a caseload of patients and coordinates care with a multidisciplinary team.

* Supervises the home health aides every 14 days in accordance with federal/state guidelines and agency policy.

* Collaborates with and supervises the nursing care provided by the LPN. Conferences with LPN on shared patients when there are changes in the plan of care or status of the patient.

* Conferences with other disciplines regarding the status of shared patients and consistently documents interdisciplinary coordination and communication activities in the clinical record. Attends interdisciplinary conferences in accordance with agency policy. Makes appropriate notifications in advance of the conference if unable to attend.

* Maintains patient caseload and keeps clinical manager informed of current caseload in accordance with agency guidelines.

* Appropriately informs the physician and other involved agency staff of any adverse changes in patient's condition, safety issues, changes in plan of care and discharge plans.

* Informs supervisor of any potential or actual client concerns, risk management issues and referrals to Child/Adult Protective Services 100% of time.
1.3 7%
Appropriately communicates information in accordance with agency policies and procedures and discipline specific guidelines.

* Completes all forms accurately and in accordance with agency guidelines/policies.

* Appropriately describes the patient's functional limitations to justify homebound status.

* Documents all verbal orders for new or changed orders according to agency guidelines.

* Completes clinical notes in…