Lahey Health is a vibrant and growing health care system, recognized as a trailblazer in medicine and a standard bearer in patient experience. It includes an award-winning academic medical center, a superb constellation of community hospitals, home care services, rehabilitation facilities and more.
We are committed to attracting, developing and retaining top talent in a market long recognized and revered as a global leader in health. With a team approach to care, we encourage learning and growth at all levels, and we offer competitive salaries and benefits. We adhere to the principles of a just and fair work environment for all colleagues, where respect is foundational and performance is rewarded.
About the Job
The registered nurse plans, organizes and directs home care services and is experienced in nursing, with emphasis on community health education/experience. The professional nurse builds from the resources of the community to plan and direct services to meet the needs of individuals and families within their homes and communities in accordance with home care regulations and payer guidelines.
Full time - 40 hour day position
Essential Duties & Responsibilities including but not limited to:
- Assumes responsibility to coordinate patient care for assigned schedule including but not limited to: appropriate delegation to LPN staff, patient condition change visits, and completion of OASIS time points. Accepts accountability for patient satisfaction scores and quality of care outcome measure results.
- Completes and documents an initial assessment of patient and family to determine home care needs. Provides a complete physical assessment and history of current and previous illness(es).Develops a patient specific plan of care, which establishes goals based on nursing diagnosis and incorporates therapeutic, preventive, and rehabilitative nursing actions. Includes the patient and the family in the planning process.
- Initiates the plan of care and makes necessary revisions as patient status and needs change.
- Initiates appropriate preventive and rehabilitative nursing procedures. Administers medications and treatments as prescribed by the physician.
- Counsels the patient and family in meeting nursing and related needs.
- Respects and supports patient and family’s cultural beliefs and values, individual needs, health goals and treatment preferences.
- Provides health care instructions to the patient as appropriate per assessment and plan of care.
- Instructs, supervises and evaluates home health aide care provided every two (2) weeks, as needed.
- Manages plan of care in accordance with evolving nursing care needs and continued eligibility for services.
- Identifies discharge planning needs as part of the care plan development and is in communication with the primary RN Case Manager.
- Communicates with the physician regarding the patient’s needs and reports any changes in the patient’s condition; obtains/receives physician’s orders as required.
- Attends regular case conferences and team meetings per Clinical Coordinator and as needed.
- Communicates with team LPN when delegating appropriate visits, after an admission to services.
- Communicates with other community providers to coordinate the care plan (i.e. Protective Services, Insurance case managers, high risk case managers, elder services, protective service, etc).
- Practices confidentiality principles set by the agency and federal HIPAA guidelines.
- Demonstrates proficiency in OASIS completion.
- Clinical visit notes explain the need for the skilled nursing service in light of the patient’s overall medical condition and experiences; the complexity of the services performed and the plan for the next visit based on the rationale of prior results.
- Completes documentation in accordance with agency timeliness policies.
- Maintains and updates clinical knowledge and skills based on current nursing practice.
- Adheres to departmental requirements for required training.
- Identifies specific learning needs and goals and collaborates with nursing leadership in developing a plan to meet them.
- Ensures that arrangements for equipment and other necessary items and services are available.
- Participates in in-service programs and supervises, teaches and precepts other nursing personnel per Clinical Coordinator.
- Registered Nurse from a Graduate of National League for Nursing accredited school of nursing.
- BSN, strongly preferred.
Licensure, Certification & Registration:
- Registered nurse with current licensure to practice professional nursing in the state of Massachusetts.
- Maintains a current American Heart Association (AHA) CPR certification
- Minimum of 1-2 years nursing experience, at least one of which is in the area of home care nursing with OASIS experience.
Skills, Knowledge & Abilities:
- Demonstrates excellent observation and problem solving/critical thinking skills.
- Well-developed verbal and written communication skills
- Essential computer skills to work with EMR.
- Must be a licensed driver with an automobile that is insured in accordance with state or organization requirements and is in good working order.
- Self-directed and able to work with minimal supervision
- Shows strong ability to organize and prioritize workload independently; nursing skills per competency checklist.
Benefits offered for any position with over 20 scheduled standard hours:
- Voluntary Insurance choices for Medical, Dental, Vision, Disability, Life, Auto and Home, and Pet Insurance available
- Lahey Outpatient Pharmacy Benefits
- Paid Time Off or (PTO)
- Tuition Assistance for 20 hours or more per week after 1 year of continuous benefits employment
The Lahey Model of Care—right care, right time, right place—is exactly what patients, providers and payers need and deserve. Identifying and delivering on this convergence of interests has positioned Lahey Health for further growth. Our model ensures care is highly coordinated and locally delivered, with lower costs and exceptional quality.
Lahey Health is a robust, regional system including a teaching hospital, community hospitals, primary care providers, specialists, behavioral and home health services, skilled nursing and rehabilitation facilities, and senior care resources throughout northeastern Massachusetts and southern New Hampshire. The system has a global presence with programs in Canada, Jordan and Bermuda.
Equal Opportunity Employer/Minorities/Females/Disabled/Veterans.