Coordinates the delivery of all the care/services appropriate to the needs of the patients of all ages and their families using an interdisciplinary team approach. Develops a plan of care with specific goals for each patient considering the physical and psychosocial assessment of the patients in collaboration with the physician. Provides ongoing case management of patients which includes the provision of necessary education and support to the clients and caregivers, monitoring progress, providing nursing care and managing reimbursement requirements. Delegates duties ro RN's, LPN's, and paraprofessional staff, supervising them in the field according to policy. Collaborates with the Supervisor/Director on issues related to case management, employee issues, etc.
Performs a total systems assessment according to established policies (including physical, psychosocial and spiritual data) upon admission, as well as onging assessments.
Assesses family and support system active in the patient's place of residence.
Analyzes assessment data, identifies problems and develops the plan of care in collaboration with the patient, caregivers, and resource personnel.
Identifies expected outcomes which are realistic, measurable and attainable.
Collaborates with the interdisciplinary team to develop an appropriate discharge plan.
One year of acute or long term care nursing experience.
One year of homecare experience.
Graduate of an accredited RN program required.
Current RN Minnesota licensure required.
Current BLS certification required and maintains certification required.
Excellent organizational and documentation skills, current MN drivers license and insurance required.
One year of homecare experience preferred.