Visiting Nurse Upstate - Your Health Organization

GENERAL DESCRIPTION

The role of the Visiting Nurse position is to serve as an extender of the primary nurse practitioner in the provision of proactive, preventative, patient-centered care. Communication, collaboration, follow-up, and response time are critical. As a critical part of the patient’s care team, the Visiting Nurse may visit new admissions, in the event of an acute issue, as a follow-up, to provide education, to evaluate, assess and facilitate a telehealth visit in the event the provider is unable to visit. Provide quality healthcare in adherence to all applicable laws, regulations, and policies within the scope of practice. The Visiting Nurse will be required to travel to patients’ homes, long-term care facilities, offices, etc. to assess patients and initiate telemedicine visits. AREAS OF RESPONSIBILITY

A successful Visiting Nurse will be able to perform these essential duties and responsibilities. Reasonable accommodations may be made, in accordance with applicable law, to enable individuals with disabilities to perform the essential functions.

The following is a list of essential functions, which may be subject to change at any time and without notice. Management may assign new duties, reassign existing duties, and/or eliminate function(s).
Admission
•Facilitate a telehealth visit with the nurse practitioner and a tele-pharmacy visit with the pharmacist
•Facilitate receiving all medical records from the patient’s primary provider and specialists
•Review all medical records of new patients
•Assess and admit new patients
•Enroll patients in chronic care management (CCM) if they meet CCM eligibility criteria
•Initiate a Chronic Care Management Plan of Care if the patient is eligible for CCM
•Capture all diagnoses at the highest specificity by creating GAPs and ensure they are accepted
•Complete AWV to be reviewed with the patient by the primary care provider
•Complete ACPs to be reviewed with the patient by the primary care provider
•Review and reconcile prescribed and OTC medications, vitamins, supplements, and herbal remedies.
•Assess for home health, hospice, palliative, or SCHC specialists
•Assess for devices (Livi, RPM) or services (SCHomeRX, meals-on-wheels), or tools that may improve thepatient’s quality of life
•Communicate and coordinate care
Discharge from an acute or post-acute facility or home health
•Facilitate a telehealth visit with the nurse practitioner and a tele-pharmacy visit with the pharmacist
•Review and reconcile prescribed and OTC medications, vitamins, supplements, herbal remedies, and othertreatments•Provide post-discharge education•Communicate and coordinate care
Acute Incident
•Facilitate a telehealth visit with the nurse practitioner and a tele-pharmacy visit with the pharmacist
•Assessment of acute condition(s)
•Communicate and coordinate care
•Initiate and implement a plan

Patients and Caregivers Education and Communication
•The added value of chronic care management (CCM)
•Medications, procedures, and treatment protocols
•The importance of satisfying quality measures
•Proper healthcare procedures strategies
Management of Medication & Treatments
•Taking and monitoring vital signs
•Monitoring and documenting patient care• Performing and documenting assessments of patients’ physical and mental health•Review and reconcile prescribed and OTC medications, vitamins, supplements, and herbal remedies.
•Administration of prescribed medications, treatments, and therapies•Administering oxygen and other respiratory treatments.•Monitoring patients after treatments or medications.•Completing wound assessment and administering treatments•Giving immunizations, ppd, and other injections.•Preparing IVs and supplies•Assist with Retinavue - Diabetic Eye Exams
Chronic Care Management
•Educating and enrolling patients in chronic care management (CCM)
•Communication, collaboration, and coordination of care
•Continuous review and revision of CCM plan of care
Hospice
•Facilitate a telehealth visit with the nurse practitioner for coordination of care.
•Coordinate with the patient’s hospice interdisciplinary team and other individuals in the patient's care plan.
•Participate in the hospice IDG meeting
Assisted Living & Skilled Nursing Facilities
•Rounding with physicians in assisted living or skilled nursing facilities
•Coordinate with the patient’s health care team, physicians, physical and occupational therapists, home health orhospice representatives and other individuals in the patient’s care plan.
Administrative
•Capture all diagnoses at the highest specificity by creating GAPs and collaborate to ensure they are accepted.•Accurately document each visit and interaction•Assess and chart observations of the patient’s condition.
•Collaborate with nurse practitioners to satisfy each patient’s quality measures.
•Facilitate telehealth or tele-pharmacy visits
•Coordinate with your Director of Clinical Services to review analytics related to your patient cohort (i.e. Acclivity,PowerBI)
•Ensure follow-up visits are scheduled
•Participate in quality improvement projects i.e. root cause analysis of adverse incidents
•Maintain current list of providers and specialists updated in the EMR
•Communicate with patients, families, and caregivers.
•Must be available during normal work hours (unless previously approved by direct supervisor). Additionalhours may be required to complete normal business functions and/or projects.
•Utilize the company’s software systems and update information as required.
•Participate in coaching calls.
•Perform other duties as requested or required, in the sole discretion of SC House Calls.

MISSION EXPECTATIONS
•Take responsibility for own work in completing tasks. Assist others so that the resources, assistance orsupport is provided to achieve success in their daily work.
•Communicate, endorse, and demonstrate SC House Calls’ mission, vision and values.
•Prompt and regular attendance.
•Adhere to standards of behavior, dress code including name tag and approved uniform, personnel departmentand company policies.
•Attend in-services and meetings on a regular basis.
•Promote a culture of outstanding customer service at all times.
•Must be available during normal work hours (unless previously approved by direct supervisor). Additional hoursmay be required to complete normal business functions and/or projects.
•Must possess the ability to deal tactfully with patients, employees, management, visitors, government agencies ,and the general public and maintain an open-door policy for all employees.
•Must possess the ability to make independent decisions when circumstances warrant.

WORK ENVIRONMENT
The work environment characteristics described herein are representative of those an employee encounters while performing the essential functions of the job:
•May be exposed to housekeeping cleaning agents and chemicals, humidity, hot equipment, and/or noise.
•May be exposed to infections, communicable diseases, odors, bloodborne pathogens, excreta and hazardous materials.

COMPLIANCE WITH POLICIES AND PROCEDURES
•Comply with all federal, state and local laws and regulations.
•Knowledge of and compliance with Patient’s Bill of Rights.
•Must be knowledgeable of Medicare guidelines, applicable laws and regulations, and SC House Calls policy and procedures.
•Adhere to SC House Calls’ Code of Conduct / Ethics.
•Must exercise a high degree of confidentiality regarding patients, personnel and the company.
•HIPAA compliant.
•Promote a culture of compliance.

PHYSICAL DEMANDS
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of the job. Reasonable accommodations may be made, in accordance with applicable law, to enable individuals with disabilities to perform the essential functions.
•Must be able to lift, reach, bend, push, pull, use repetitive hand motions, walk and carry simultaneously.
•Must be able to withstand reaching, stooping, bending, kneeling, and crouching; walking and standing for periodsof time; lifting up to fifty (50) pounds.
•Must be in good general health and demonstrate emotional stability.

QUALIFICATIONS
•Must be a licensed nurse. License must be in good standing with the appropriate board.•A minimum of three (3) years clinical experience preferred.•Demonstrated ability to supervise and direct professional and administrative personnel.•Ability to read and communicate effectively.•Strong written and verbal skills.•Basic computer knowledge.•Ability to manage and demonstrate effective leadership skills.•Should demonstrate good interpersonal and communication skills under all conditions and circumstances.