Coordinator serp_jobs.h1.location_city

The LPN Intake Coordinator / Educator is responsible for coordinating all new referrals made to the agency, ensuring that all new referrals meet the agency's policies and procedures as well as federal / state regulations and guidelines.

Patient Care :

• Maintains working knowledge of current home health coverage guidelines, admission criteria, documentation requirements, coding guidelines, and care planning with case conferences; manages patient care accordingly.
• Effectively manages initial home visit; introducing services, admission criteria, the process for determining patient eligibility, and obtaining required consents when eligibility is confirmed.
• Assesses the patient / caregiver's willingness, ability, and barriers to learn patient care techniques and for achieving independence in care; documents patient and family response to teaching.
• Outlines aide care plan; performs ongoing home health aide oversight, revises aide care plan based on patient progress; evaluates home health aide care every 14 days or per state payer requirement and state regulations.
• Supervises CAN participation in patient's plan of care and performance of skilled interventions at intervals defined by state regulations.
• Initiates the plan of care and related nursing interventions; conducts goal-oriented visits; ensures other nursing team members have the information needed for continuity of care and continued progress.
• Provides patient / family teaching per POC; assesses and documents response to teaching.
• Advocates for the patient as required.
• Completes an accurate, initial comprehensive head to toe assessment. Completes for home health patients, an OASIS, and other assessments of patient and family to determine home care needs; obtains a history of current and previous illness(es).
• Uses health assessment data, input from agency team members, the physician, patient and family, to determine patient needs.
• Effectively manages patient and family expectations regarding agency services, outcomes / discharge goals and ability to achieve independence in care.
• Establishes appropriate primary and secondary diagnosis based on patient assessment and focus of home health care.
• Develops a care plan, incorporating appropriate skilled interventions, and necessary medical supplies / equipment and ancillary / specialty services, to achieve outcome / discharge goals.
• Protects realistic home health visits by discipline and medical supplies required per planned interventions and discharge goals. Write POC orders accordingly.
• Regularly evaluates home health patient's progress, in collaboration with team members; revises patient POC accordingly.
• Performs ongoing appropriate OASIS assessments and revises POC accordingly.
• Identifies home health patients' discharge planning needs when developing the plan of care; identifies and implements community referrals before patient discharge; determines patient readiness for discharge based on expected outcomes, goals, and coverage guidelines.

Coordination :

Additional Duties :

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