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Overview

Provides high quality comprehensive nursing care to meet the needs of the patient/client and manages/coordinates the delivery of cost effective multidisciplinary health care services for a caseload of patients/clients consistent with VNS Health philosophy, policy, goals and objectives, and Standards of Nursing Practice. Works under moderate supervision.

For Nurse-Family Partnership (NFP) only: Provides health education, social support and community linkages to meet the needs of pregnant and postpartum, first-time mothers and their infants. Also responsible for adhering to NFP national guidelines.

• Assesses the physical, social and psychological needs and environmental conditions of the patient/client through professional knowledge, skills of observation, interviewing, and physical examination to develop a plan of care.
• Understands, interprets, and implements reimbursement protocols; determines the billing source for patient/client care. Consults with management on complex/unique reimbursement cases.
• Acts as the coordinator of care for the multidisciplinary team by providing and managing the care needs of patients/clients which includes making/confirming referrals to other disciplines/community agencies and ordering supplies/services and ensuring they are delivered as needed.
• Documents content and process of all services provided in accordance with government regulations/requirements, and VNS Health policies, practices, and procedures, as well as NFP requirements as appropriate. Initiates and maintains written (including clinical and progress notes) and verbal communications with team members and management to assure optimal patient/client care.
• Participates in the orientation of selected staff through buddy system field observation of staff and feedback to appropriate staff involved in orientation process.
• Participates in selected student programs by providing guidance, training and mentoring to students.
• Provides nursing care in accordance with VNS Health policies, practices, procedures and Standards of Nursing Practice, which may require standing, stooping, sitting, crouching, bending and stretching to deliver patient/client care.
• Transports and utilizes required medical equipment and other supplies using VNS Health designated/supplied carrying case weighing approximately 25 30 lbs. to and from patient/client homes/care facilities.
• Travels to patient/clients homes and/or other facilities with varying environments (e.g., elevated buildings, walk-ups, care facilities, single/multiple family homes, presence of pets, etc.) using approved transportation options to deliver direct care to the patient/client.
• Follows work procedures in relation to established workflows.
• Maintains productivity sufficient to meet VNS Health goals.
• Assumes responsibility for personal professional growth through attendance at in-services, training, continued formal education and select journal readership.
• Performs other related duties and participates in special project, as assigned.

For CHHA and Hospice Only

• Establishes, implements, and revises a plan of care with input from appropriate multidisciplinary health team members (i.e., physician, OT, PT, SW, SLP, family members, caregivers, HHAs, etc.) based on goals mutually acceptable to the patient and significant others. Ensures that services follow the plan of care by ongoing assessment, planning, coordination, counseling, teaching and supervision of the delivery of care to meet the needs of the patient.
• Oversees/supervises the care provided to the patient by Licensed Practical Nurses and Paraprofessionals through regular home visits in compliance with regulatory and VNS Health requirements. Assesses the patients condition, monitors the effect of the care plans on the patient/family health status, informs physician and other team members of changes in the client's needs and updates the plan of treatment, as needed.
• Manages, plans, coordinates and executes the patients safe discharge from service. Ensures that physicians orders, discharge summary and communication to team members, patient and family members adhere to VNS Health and regulatory requirements.
• Communicates and consults with patients MD and follows-up on problematic situations affecting care such as abnormal clinical findings, medication discrepancies, or other factors that impact patients ability to comply with the plan of care. Manages and coordinates all aspects of assigned caseload.
• Assists patients with activities of daily living, which may require positioning, moving, transferring and lifting patients of varying weights and physical conditions, with and without assistance and as appropriate, from family members and/or paraprofessionals.

For NFP Only

• Establishes, implements, and revises a plan of care with input from the client and from appropriate multidisciplinary health team members (i.e., social worker, physician) based on goals mutually acceptable to the client. Ensures that services follow the plan of care by ongoing assessment, planning, coordination, counseling, teaching, and evaluation of the delivery of care to meet the needs of the client.
• Manages, plans, coordinates and executes the clients safe discharge from service. Ensures that discharge summary and communication to team members, patient and family members adhere to VNS Health and regulatory requirements.
• Maintains a flexible work schedule to meet client's needs.
• Participates in all required NFP training sessions.
• Participates in special projects and performs other duties as assigned.

Licenses and Certifications:

• License and current registration to practice as a registered professional nurse in New York State required.
• Valid driver's license or NYS Non-Driver photo ID card, may be required as determined by operational/regional needs.

Education:

• Degree in Nursing from an approved program required.
• Bachelor's Degree NFP Only- Nursing required.

Work Experience:

Experience for CHHA:

• Minimum of one year of experience in a medical/surgical environment required.
• Experience for Hospice:
• Minimum of one year of clinical nursing experience, including at least six months of Hospice, or Med/Surg or ICU or Emergency Dept or Home care, Palliative Care, Oncology or Long Term Care experience required.