Job Description

Responsible for coordinating and directing the delivery of care for an assigned case load of patients who are receiving services in the home setting in collaboration with the interdisciplinary care team and Home Health Care Navigator. Determines home health as the appropriate level of the care for the patient as well as skilled need for services ordered based on home health Conditions of Participation. Initiates, reviews, evaluates, and revises the established plan of care in collaboration with the physician, interdisciplinary team, and Home Health Care Navigator to for appropriate care plan progression aimed at achieving patient goals, quality metrics, and level of care transition through discharge planning. Performs initial and ongoing assessments and skilled treatments and interventions as ordered by the physician and provides patient/caregiver education aimed at achieving patient goals/outcomes. Coordinates and directs the delivery of care for an assigned case load of patients who are receiving services in the home setting in collaboration with the interdisciplinary care team and Home Health Care Navigator. Initiates, reviews, evaluates, and revises the established plan of care in collaboration with the physician, interdisciplinary team, and Home Health Care Navigator for appropriate care plan progression aimed at achieving patient goals, quality metrics, and level of care transition through discharge planning. Works in collaboration with other network entities to ensure appropriate delivery of patient care and care progression. These programs include but are not limited to Wound Center, Remote patient Monitoring, Transition of Care Teams, Case Managment, Care coordinator/navigators, and PCP / Specialist Physician offices. Responsible for completing the OASIS data collection as per CMS regulation with a high level of accuracy that reflects quality outcomes measures and appropriate financial reimbursement for services. Formulates an individualized plan of care according to physician orders that incorporates the analysis of assessment data and current scientific findings. Collaborates with the physician and Home Health Care Navigator. Determines home health as the appropriate level of care for the patient as well as skilled need for services ordered based on home health Conditions of Participation. Relays significant changes in patient status to the physician and other members of the interdisciplinary care team in a time period consistent with patient needs. Delivers patient care based on the medical plan of treatment established by the physician and protocols using a patient family centered approach. Provides educational opportunities for patients, families, and clinical staff focusing on end-of-life issues, palliative care, advance directives, chronic disease management, pain management, symptom control, home care, hospice, and discharge planning. Promotes patient/caregiver autonomy. Evaluates effectiveness of teaching and modifies education based on patient needs and goals.

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