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. Maintains productivity levels per agency standard.
• 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. Identifies problems accurately. Establishes reasonable/measurable goals. 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 as prescribed by patients physician and in compliance with Home Health Services established standards, policies, and procedures. Evaluates patients response to identified interventions. Reviews and interprets laboratory values. Demonstrates knowledge and skill in providing wound care. Provides all care according to established, written plan of care. Modifies/updates/changes plan of care when indicated by patients condition and/or physician orders. Obtains physician orders as required by State and Federal laws. Initiates appropriate preventative and rehabilitative nursing procedures.
• Recognizes and interprets significant physiological and behavioral changes in patients condition. Reports findings appropriately to physician, Home Health Manager and/or other individuals involved in care of patient. Demonstrates critical thinking such as problem-solving, reflective practice, clinical reasoning, prioritizing, etc. Determines in conjunction with physician, when patient care needs to be shifted into another setting. Re-evaluates patients nursing needs regularly when licensed practical nurse furnishes services.
• Instructs patient, family, and other caregivers on nursing and aide-related care to promote independence and self-care.
• Provides case management, as caseload assigned. Coordinates all necessary services to be provided to patients. Integrates all services into plan of care.
• Documents all care provided to patients and plans pertaining to care according to Home Health Services standards, federal and state regulation(s). Assures that medical record is accurate, legible, and complete; and completes accurate daily visit log. Completes assessments and documentation per State and Federal law (e.g. OASIS) for all applicable patients assigned. Submits documentation in timelines specified by Home Health Standards, Federal and State regulation(s).
• Develops area of clinical expertise within Home Health Nursing, and provides instruction/supervision in area to others in agency, as requested. Provides guidance and supervision to 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. Communicates with other Home Health personnel, other departments and with community resources to coordinate care and services for Home Health Services patients.
• Participates in Home Health Services functions such as staff meetings, staff in-services, and committees, as assigned. 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). Identifies and reports infections of patients. Assists with development and implementation of departments annual work plan. Performs clinical record audits, as assigned. Maintains educational record and provides evidence of competency.
• Prepares weekly schedule of patient visits for self, and licensed practical nurse, and keeps Referral Center apprised of schedule changes and openings for new admissions and other added visits. Rotates weekend, holiday and after hour coverage with other Home Health nurses, as required.
• Notifies Home Health Manager and/or designee of unusual circumstances or abnormal conditions which might result in schedule change for self or other employees. Reports problems, incidents and/or concerns to Home Health Manager in timely manner.
• Follows all applicable laws, rules and recommendations for safe driving while on duty.
• Provides verification of current licensure/certification.
• Maintains, uses, and responds to (as applicable): voicemail, pager, e-mail, and computer.
• 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.