Welcome To Beth Israel Lahey Health at Home. Our team provides high-quality home care and hospice services by partnering with physicians, hospitals and skilled nursing facilities to provide specialized care to patients in the comfort of their own home. Our team of nurses, therapists (physical, occupational, and speech), medical social workers, and home health aides work together to devise and implement a compassionate care plan that is expressly tailored for each patient.
Beth Israel Lahey Health is dedicated to improving health and wellness and making a difference in the lives of our patients, their families and all members of the communities we serve. Formed in March 2019, Beth Israel Lahey Health is a patient-centered, integrated care delivery system providing a continuum of services spanning academic, tertiary and community hospitals, dedicated orthopedic and psychiatric hospitals, primary and specialty care, community acute care, ambulatory care, behavioral services and home health.
Equal Opportunity Employer/Minorities/Females/Disabled/Veterans.
Essential Duties & Responsibilities including but not limited to:
- Provides telephone triage for symptom management and follows up to determine effectiveness
- Provides visits as needed based on symptom management need
- Manage care of patients, coordinate all services and facilitate communication between all providers.
- Provide skilled nursing care and prescribed treatments to patients and families in their home.
- Maintain productivity expectations.
- Provide documentation of services utilizing problem-oriented record.
- Plan for continuity of care with nursing team members, patient, family, and other disciplines.
- Use opportunities for teaching nursing care, comfort measures and health practices to the patient, families and others.
- Instruct and supervise care given by the Home Health Aides.
- Communicate and coordinate with other health and social agency personnel to assist in planning, implementing, evaluation service to the patient and family.
- Participate in bi-weekly hospice case conference or as required.
Assumes responsibility to coordinate patient care for assigned patients including but not limited to:
- Completion of Hospice Item Set (HIS) 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, as assigned, to determine hospice 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 palliative nursing actions, with emphasis on pain and symptom management. Includes the patient and the family in the planning process.
- Initiates the plan of care, as assigned, and makes necessary revisions as patient status and needs change.
- Administers medications and treatments as prescribed by the physician.
- Counsels the patient and family in meeting patient needs related to physical, emotional, and spiritual needs.
- Respects and supports patient and family’s cultural beliefs and values, individual needs, health goals and treatment preferences.
- Provides information to the patient and family regarding the dying process and expectations.
- Provides instruction regarding medication actions, side effects, dosage, route, and frequency.
- Instructs, supervises and evaluates hospice health aide care provided. Supports the supervision of care provided by the hospice aide every two (2) weeks minimally, and as needed.
- Assists in managing the hospice benefit periods in accordance with evolving patient needs and continued eligibility for services.
- Performs liaison visits and hospice informational visits to patients in the community and in facilities to discuss hospice and palliative care services
- Communicates with the physician and the Hospice RN Case Manager regarding the patient’s needs and reports any changes in the patient’s condition; obtains/receives physician’s orders as required.
- Attends and contributes to IDT meetings every two weeks at a minimum, and as needed.
- Communicates and coordinates with the team LPN as appropriate.
- Collaborates, communicates, and cooperates as appropriate with other health care providers to ensure quality end-of-life care.
- Demonstrates proficiency in HIS completion.
- Documentation supports hospice eligibility.
- Documentation supports that the patient meets hospice criteria ongoing.
- 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 & goals and collaborates with nursing leadership in developing a plan to meet them.
- Participates in the weekend/holiday/on-call rotation as defined by BILH at Home.
- 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 as assigned by Clinical Manager.