Provides comprehensive skilled nursing care and services to patients in the home setting.  Works on an interdisciplinary team to provide care in the home health, palliative care and hospice programs. Accountable for the assessment, development of plan of care, education and consultation related to pain and symptom management as well as adjustment to changes in health status. Plans for the return of patient care to primary Health Care providers as indicated.

• Communicates and collaborates with other inter-disciplinary team members and with the patient family in planning and implementing care. Records accurate and pertinent data in the electronic medical record in a timely manner, according to documentation guidelines.  


• Adheres to KFHPW infection control, safety, hazardous waste, universal precautions, and CPR standards.


• Provides nursing interventions requiring substantial and specialized nursing skill and initiates appropriate preventive and rehabilitative nursing procedures.


• Follows through the plan of care as developed to provide appropriate instruction to patient/caregiver about health care, disease management and adjustment to illness; direct and supervise the care and services of LPN and HHA in the home setting; perform treatments; instruct patients/families in self-care activities and home safety; and competently perform skills/tasks per plan of care. 


• This includes pain and symptom management in the home.  


• Performs skilled procedures to include injections, dressings, catheter insertion and care, colostomy and tracheotomy, central line IV care and blood draws. Identifies educational needs.


• Instructs patient according to the plan of care. 


• Provides care and case management with interdisciplinary team.


• Identifies own learning needs, including those related to age-specific populations and participates in educational efforts to meet those needs.


• Participates in the following: staff orientation; self and colleague/team performance reviews; and activities related to quality care and cost saving measures. 


• Adheres to KFHPW personnel policies and maintains a high standard of professional work habits.


• Demonstrates an appearance consistent with KFHPW dress code policy.


• Assesses patient need for care and communicates with other health care providers appropriately and in a timely manner.


• Collects data relevant to visit throughout the duration of care. 


• Develops and initiates the plan of care based on assessment.  


• Communicates and collaborates with medical doctor(s) to establish plan of care.


• Evaluates patient response to care through timely assessment, communication and observation.


• Modifies plan of care through assessment based upon patient and care systems response.