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Furnishes those services requiring substantial and specialized nursing skill. Initiates appropriate preventative and rehab nursing procedures.
Prepares & submits timely, clinical and progress notes. Oversees coordination of patient services.
Informs MD and other staff of changes in PT situation or needs. Completes medical history/home safety check/environmental assessments. Performs socio-psychological evaluation.
Performs assessment visit and documents timely. (ie. OASIS/ Skilled Nursing Note etc.). Performs physical examination and review of all body systems and documents accordingly. Develops individualized Plan of Care (POC) to be submitted to the physician for approval and implementation and performs necessary revisions based upon patient needs.
Determines medical necessity for other services. Regularly re-evaluates the patient’s nursing needs.
Evaluates the patient’s ADL and iADL abilities and need for home health aide.
Develops and implements the HHA plan of care when HHA services are ordered. Revises and signs this care plan the beginning of each certification period.
Supervises HHA in accordance with state/federal requirements and documents the supervision. Orders “other” professional services that may be appropriate to the needs.
Reviews billing processes with patient and/or family advising patient and/or family when co-pay or Medicare is not likely to pay for services.
Effectively communicates ongoing with patient and family progression/changes in POC. Effectively communicates with Supervisor/Nursing Director/other disciplines in the case. Communication with the patient’s MD (verbally and/or in writing) to obtain effective treatment modalities and/or rehabilitative therapy modalities.
Actively communicates in the case conferencing sessions to establish best practices. Submits requests for re-authorization of “more visits needed” to payers timely.
Coordinates Community Services for the patient to assist in safe home care needs. Participates in the Performance Improvement Committee process.
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