1.      Completes initial, comprehensive, ongoing, and reassessment activities patients according to patient needs, assigned program requirements, and location-specific workflows.

2.      Develops, implements, and updates individualized plans of care in collaboration with physicians, patients, families/caregivers, and interdisciplinary teams.

3.      Provides direct nursing services and case management support in accordance with the plan of care, physician orders, and agency policies.

4.      Communicates with physicians, branch leadership, and interdisciplinary team members regarding patient needs, response to treatment, changes in condition, and required orders.

5. Organizes and performs work effectively and efficiently.

6.      Maintains and adjusts schedule to support deployment needs, assignment timelines, and agency performance.

7.    Demonstrates a daily commitment to the values of the agency.

8.    Demonstrates positive interpersonal relations in dealing with all members of the agency.

9.    Maintains and promotes customer satisfaction.

10.  Effectively demonstrates the mission, vision, and values of the Agency on a daily basis.

30%

QUALITY OF WORK

1.1 10%

Utilizing all aspects of the Nursing Process (assessment, planning, implementation, evaluation) with appropriate skill to effectively manage Home Health patient care across assigned deployment locations as evidenced by:

• Assessing patient and family/caregiver physical, psychosocial, environmental, safety, developmental, palliative, bereavement, and clinical needs as applicable to the assigned program.
• Providing and/or facilitating patient and family/caregiver education according to the plan of care, including disease process, medications, safety, symptom management, agency philosophy, and available resources.
• Providing developmental interventions appropriate to patient’s age and clinical status.
• In collaboration with the patient/family, physician, branch leadership, and assigned clinical team, performs and documents thorough and timely assessments to support eligibility, care planning, and continuity of services.
• Completing reassessments, recertification activities as applicable, service line updates, and plan of care revisions within required timeframes and in response to significant changes in clinical status, support system, or care environment.
• Obtaining physician orders and utilizing data collected during assessments, agency teaching guidelines, nursing interventions when applicable, and appropriate nursing skills to implement and follow the established plan of care while adapting to assigned branch processes.

1.2 7%

Effectively and efficiently manages assigned patient care responsibilities and coordinates care with interdisciplinary teams across deployment locations.

• Supervising assigned aides, LPNs, and other delegated services in accordance with Medicare, federal/state guidelines, program requirements, 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.
• Participating in interdisciplinary conferences when applicable, and care coordination activities in accordance with agency and program requirements.
• Maintaining assigned caseload, visit responsibilities, or temporary coverage assignments and keeping branch leadership informed of workload, barriers, patient care needs, and staffing needs.
• Appropriately informs the physician, branch leadership, and involved agency staff of adverse changes in patient condition, pain or symptom concerns, safety issues, changes in plan of care, and discharge or transition plans.
• Inform supervisor of any potential or actual client concerns, risk management issues and referrals to Adult Protective Services 100% of time. Complete documentation in the medical record and initiate PI notification via Health Care Safety Zone portal of these concerns and action taken.

1.3 8%

Appropriately communicates and documents information in accordance with agency policies, Home Health and Hospice program standards, assignment expectations, and location-specific workflows.

• Completes all forms accurately and in accordance with agency guidelines/policies.
• Documents patient eligibility, functional limitations, homebound status, hospice eligibility, symptom management needs, and other required clinical findings as applicable to the assigned program.
• 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, family/caregiver, physician, hospice physician when applicable, and interdisciplinary team in developing and revising the plan of care.
• Consistently documents interdisciplinary, interagency, and cross-location communication and coordination of services per agency guidelines.

1.4 5%

Contributes to Clinical Resource Team and program effectiveness across Home Health Region by:

• Demonstrating understanding of Home Health interdisciplinary team approaches, continuum of care needs, and purpose of supporting high-need locations.
• Incorporating recommendations and goals of other disciplines, patient/family/caregiver, branch leadership, and interdisciplinary meetings into nursing visits and care coordination.
• Demonstrating willingness and ability to travel, accept temporary assignments, and accommodate agency needs in order to provide optimum patient care.
• Accepting constructive criticism as evidenced by implementation of suggested actions for improved performance.
• Promotes change while seeking new opportunities to improve workflows and introduce new ideas.
• Demonstrating ability to prioritize and enhance services during fluctuating patient census, vacancies, leaves of absence, home health coverage needs, and other deployment triggers.

2.0      20%           EFFICIENCY AND EFFECTIVENESS:

2.1 10% 

Organizes and performs work effectively and efficiently while deployed to assigned locations 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 and assignment-specific goals for patient care, documentation, and operational support.
• Maintaining a clean and safe environment

2.2     10%           

Maintains and adjusts schedule to enhance team performance, deployment readiness, and continuity of care as evidenced by:

• Reporting to work on time and returning promptly from errands, breaks, and meals.
• Managing personal work schedule, travel schedule, and time off to promote smooth agency operations and successful assignment completion.
• Demonstrating flexibility with changing workload, assignments, geography, census needs, and temporary deployment timelines.
• Traveling to all counties within respective region to provide coverage for pre-planned PTO, call-outs, FMLA, and uncovered territories.

3.0      50%           TEAM WORK, MISSION, VISION, VALUES:

3.1      25%           

Demonstrates positive interpersonal relations in dealing with all members of the team across assigned locations (i.e. co-workers, supervisors, physicians, branch leadership, 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, resources, and best practices across deployment locations.
• Working collaboratively and cooperating with other agency employees

3.2      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 Health and applicable Home Health regulatory requirements.
• Provide education to patients and families/caregivers on patient satisfaction surveys and encourage completion.

3.3      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