RN, Home Health (Per Diem, Days)

Description : Job Summary :

The Home Health Access RN provides quality, cost effective clinical coordination and transitions to the home from the acute care, emergency care settings, and clinic or primary care. The Home Health Access RN manages patients with routine and complex discharge planning needs through collaboration with inpatient and / or SNF care coordination. The Home Health Access RN also serve as expert resource consultants and educators for physicians and other health care team members in transitions of care to the Home Health Program, coordination of internal and community resources, and support the evaluation and improvement of systems of care to support the optimal utilization of home health resources, while maintaining quality of patient care.

Essential Responsibilities :

• Quality and Service : Providing an exceptional patient care experience, consults with patients, families, physicians and hospital staff to gather appropriate clinical and demographic data to ensure a smooth transition from hospital to home health care. Provides an exceptional patient care experience that includes appropriate patient care planning according to the needs of the patient and family / caregiver members. Collaborates with insurance companies, other managed care entities, DME providers and others to provide assistance to field staff in the Case Management process to provide an exceptional patient care experience. Promotes and maintains continuity of care for patients being discharged from the hospital, clinic or SNF to home care services.
• Communication and coordination : Triages incoming referrals based on the patient needs. Determines initial level of care and services ordered and assesses the need for additional services for patients referred to Home Health. Provides oversight and supervision for LPN and Referral Coordinators to support timely admission to the home health program. Utilize case / family conferences and consults to develop these care plans as needed. Implementing care plans by ordering, brokering, and advocating for the patient and family, while educating the patient, family, and health care team about options and alternatives. Notifies CCS Managers of any discharges of patients with complicated social and medical issues that delay initiation of home care.
• Education, documentation and program development functions : Educates patients, their families and the facility staff about the services and products provided by Kaiser Continuing Care Services. Make recommendations to modify the plan of care to expedite a safe transition of care, reduce risks, and enhance patient outcomes. Accurate documentation of all patient / caregiver contact and communication with clinic staff, PCPs, hospital care coordination in both the agency record and / or in Healthconnect to assure CCS staff are informed of all interventions undertaken in patients behalf. Ensures systematic and on-going contact with hospital staff and other Kaiser Permanente Departments (e.g. GLTC, DME, Hospital Care Coordinators, Clinic Social Workers, Clinic case Managers, Pharmacy, Home Infusion Program, Membership Services, etc) to share information and ensure safe transitions of care. Participates in quality and utilization management activities (e.g. Chart audits). Participates in continuing education to incorporate and maintain up to date knowledge and best practices in customer service and exceptional clinical care for the home setting. Completes Medication Reconciliation for therapy only cases per regulations and standards. Assists RN team with optimizing the patients home care plan by providing : Resource, support, and advice for home care staff Physician communication and support. Supply and DME ordering as needed. Assistance with paneling patients with physicians.
• Regulatory : Ensure regulatory and compliance standards are met for admission to home care programs. Understands Medicare guidelines and is responsible for adherence to all state and federal regulations and JCAHO standards.
• Productivity : Supports productivity for field staff and participates in productivity work within the CCS department.
• Covers patient advice calls as needed. Participate in program call duty as needed. Conducts patient home visits as required to assist the program in meeting patient needs. Perform other duties as requested.
• Management identifies these positions as highly skilled RNs who may provide coverage (may not always require travel to facility) for any of the below positions for vacancies with vacations or ill calls. KSMC - identifies patients discharging to the Home Health Program and make contact to assure a smooth, seemless transition that meets the patient needs. WSMC - identifies patients discharging to the Home Health Program and make contact to assure a smooth, seemless transition that meets the patient needs. SNF / clinc - identifies patients discharging to the Home Health Program and make contact to assure a smooth, seemless transition that meets the patient needs. Office - Referral triage, manage clinical aspects of referral, patient outreach to improve patient outcomes.

Basic Qualifications :

Experience

Education

License, Certification, Registration

Additional Requirements :

Preferred Qualifications :