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

1.0 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 accordance with agency guidelines and time frames.
• Documents involvement of the patient and family in developing and revising the plan of care.
• Consistently describes interdisciplinary, interagency, and intragency communication and coordination of services as per agency guidelines.

1.4 4%

Contributes to program effectiveness as evidenced by:

• Demonstrating understanding of the interdisciplinary team approach and continuum of care in accordance with the home health mission.
• Incorporating recommendations and goals of other disciplines and patient/family into nursing visits.
• Demonstrating willingness and ability to accommodate agency needs in order to provide optimum patient care.
• Accepting constructive criticism as evidenced by implementation of suggested actions for improved performance.
• Promoting change and being proactive in suggesting ideas and new ways of doing things.
• Demonstrating ability to prioritize and enhance services during fluctuating patient census.

1.5      5%   Provides practical clinical experience and guidance to field clinicians to include orientation of new clinicians as evidenced by:

• Demonstrates process for SOC, ROC, Recert, Discharge and routine visits to clinicians during the orientation process and observes employee’s ability to perform
• Observes clinical skills and patient interaction of new clinicians and provides feedback to the clinician.
• Works with clinicians to review application of clinical protocols and programs
• Reviews orientation information with new clinicians to determine the clinician’s level of understanding and re-educate as necessary
• Collaborates with Field Clinical Manager weekly to review new hire progress and address deficiencies

2.0 20% PRODUCTIVITY/USE OF TIME:

2.1 10%

Organizes and performs work effectively and efficiently as evidenced by:

• Participating in continuous performance improvement and completing all required educational programs for the Agency and profession.
• Recognizing and performing duties in an independent manner.
• Accepting personal responsibility for the completion and quality of work outcomes.
• Meeting assigned deadlines.
• Meeting productivity expectations.
• Maintaining a clean and safe environment.

2.2 10%

Maintains and adjusts schedule to enhance team performance as evidenced by:

• Reporting to work on time and returning promptly from errands, breaks, and meals.
• Managing personal work schedule and time off to promote smooth agency operations.
• Assisting other team members to ensure completion of all work assignments.
• Demonstrating flexibility with changing workload/assignments.

3.0 25% TEAM WORK:

3.1 25%

Demonstrates positive interpersonal relations in dealing with all members of the team (i.e. co-workers, supervisors, physicians, etc.) as evidenced by:

• Communicating in a positive and productive manner.
• Demonstrating respect for team members.
• Managing stress and personal feelings without a negative impact on the team.
• Maintaining positive attitude about assignments and team members.
• Promoting professional / personal growth of co-workers by sharing knowledge and resources.
• Working collaboratively and cooperating with other agency employees.

4.0 25% MISSION, VISION, VALUES:

4.1 15%

Maintains and promotes customer satisfaction.

• Responding to all customers in a courteous, sensitive and respectful manner.
• Abiding by the confidentiality and ethics policies of Well Care Home Health.
• Participates in community outreach activities that promotes goals and objectives of the agency.

4.2 10%

Continuously and effectively demonstrates customer service standards of courtesy, efficiency, and presentation as evidenced by:

• Practicing personal cost containment by responsible use of equipment, supplies, and resources.
• Completing the review period without a formal disciplinary action.*
• Presenting a clean and neat appearance in personal attire and one’s work area.
• Performing his / her job in accordance with documented procedures established to maintain the safety and health of patients, employees, and visitors and demonstrates compliance in the proper wearing and use of protective clothing and equipment to conform to the OSHA Blood Borne Pathogen Standard and also reports any exposure to the appropriate Manager in a timely manner.*

JOB SPECIFICATIONS