The Home Care Registered Nurse (HCRN) will be coordinating quality level of service with the interdisciplinary team to the target participant/patient population within the specified borough (Manhattan or Bronx).
Assesses participant s physical and functional needs, along with psychosocial status and needs, home safety, family caregiver burden, etc utilizing professional knowledge, skills of observations and interviewing skills.
Completes assessment documents including UAS, problem lists and interventions and other documentation required for appropriate data collection and analysis as part of a quality assessment and performance improvement program
Develops and implements the home care components and works with other team members to develop a comprehensive Interdisciplinary team plan of care based on the needs of participant and caregivers, and goals mutually acceptable to the participant/family and significant others.
Monitors effectiveness and outcomes regularly and keeps the team informed as to participant progress and level of need. Remains alert to pertinent input from other team members, participants and family members/caregivers. Reviews and revises goals and approaches to member/ family care in coordination with interdisciplinary team members.
Provides initial home care assessments of new members enrolled in the program, and reassesses at appropriate intervals according to PACE standards and the individualized needs of each participant in coordination with the IDT. Completes NYS required assessment tools according to the schedule planned by the IDT
Communicates with primary care providers and center nurses as needed to coordinate medication, ancillary tests and functions such as home blood draws as needed
ASN and NYS RN
UAS Certification Preferred
1-2 years of experience in geriatric/frail population and care
Must be willing to commute within specific borough of interest
Associated topics: asn, care unit, hospice, infusion, maternal, mhb, nurse, recovery, surgical, transitional