Essential Duties and Responsibilities include the following. Other duties may be assigned.
Confers with health team members, individually and in conference to exchange, discuss and evaluate patient information for planning, modifying and coordinating treatment programs.
Participates in quality improvement activities.
Collects, maintains, shares data for further development and measurement of outcomes.
Provide comprehensive care to patients as they transition from inpatient facilities to home health.
Will participate in various nursing roles as assigned.
Collaborate with case management, patients, caregivers, physician and other health team members to facilitate effective transition.
Work collaboratively with inpatient and outpatient healthcare teams to coordinate seamless individualized patient care.
Establish professional and community knowledge to obtain resources to best meet patient needs.
Participates in development of disease management strategies, measurement of patient outcomes related to hospital utilization, community outreach presentations and education.
Participates in post-acute education to community skilled nursing facilities, physicians, patients and patient caregivers.
Develops and maintains relationships with referral sources. Markets services of HealthBack Home Health.
Coordinate and attend various community education events.
Daily travel in assigned region required. Travel outside of region possible with potential overnight travel.
*LPN License required