Provides home health care to Kaiser Permanentes Home Health patients in coordination with physician orders and nursing interventions. Maintains professional, clinical, technical, and interpersonal skills to provide best possible service.

• Establishes and coordinates plan of care for patients assessing educational, equipment, skilled and non-skilled services and needs.


• Evaluates patients, families, and home environment on admission and subsequent home visits. Determines if home environment is safe and appropriate for provision of home health services. Assesses patients physical and psychosocial needs. Develops and/or revises an appropriate plan of care. Communicates and coordinates plan of care with physician(s), patients and family, and other health care providers. Implements care, as ordered. Establishes reasonable/measurable goals. Determines whether other services such as PT, OT, ST, Home Care Aide (HCA), or MSW are indicated.


• Establishes discharge planning in conjunction with the care planning process. Prepares and delivers medical supplies and orders equipment necessary for provision of prescribed care/service.


• Provides comprehensive nursing care. Evaluates patients response to identified interventions. Reviews and interprets laboratory values.


• Recognizes and interprets significant physiological and behavioral changes in patients condition. Determines, in conjunction with physician, when patient care needs to be shifted into another setting.


• Provides case management. Coordinates all necessary services to be provided to patients. Integrates all services into plan of care.


• Instructs patient, family, and other caregivers on nursing and aide-related care to promote independence and self-care. Initiates appropriate preventative and rehabilitative nursing procedures.


• Documents all care provided to patients including assessments, interventions, patient/caregiver teaching. Patient/caregiver response to care. Documents the plan for on-going care and/or discharge plan. Maintains medication profile for all medications self-administered by patient and/or administered by other. Completes accurate daily visit log. Performs clinical record audits, as assigned.


• Provides guidance and supervision to licensed practical nurse. Prepares weekly schedule of patient visits for self, and licensed practical nurse.Supervises care provided by Home Care Aides (HCA). Prepares HCA assignments. Coordinates patient care. Makes HCA evaluation visits, and provides feedback to HCA. Documents HCA supervision.


• Plans for and participates in professional development activities to keep current of trends in home health nursing and/or clinical nursing skills.


• Participates in multidisciplinary team conferences (formal and informal) to coordinate, discuss, and evaluate services provided to patient.


• Assists with development and implementation of departments annual work plan. Participates in orientation of new personnel to Home Health Services and precepts students as assigned.


• Participates in performance improvement. Identifies and presents improvement opportunities to organization and implements Quality Improvement process(es).


• Follows all applicable laws, rules and recommendations for safe driving while on duty.


• May perform patient care to the extent necessary to maintain clinical expertise, competency and licensing necessary to fulfill job responsibilities and to direct the provision of care on the unit.


• Provides direct patient care on an as needed basis. Provides services that are within scope of license and in compliance with all legal, regulatory, and policy requirements relevant to clinical role performed.


• Incorporates the KP Nursing Vision, Model and Values through out their Nursing Practice.