RN Home Healthcare

As a Home Health RN youll be a patient advocate - responsible for case management of Home Healthcare patients. Our Home Healthcare team ensures that care delivery is within quality and utilization guidelines and is directed toward the achievement of desired clinical outcomes for the disease state.

Work Schedule:

Full Time: FTE 1.0 (40 Hours per week)
Shift: Days

Sign on and relocation bonuses available for qualified candidates.

How you grow learn and thrive matters here.

• Educational and career development options including tuition and certification reimbursement scholarship opportunities.
• Staff Safety - a wearable badge that allows nurses to quickly and discreetly call for help when safety is a concern.
• Shift differentials for nights and weekends.
• Differentials for higher education certifications and various lead roles.
• Malpractice liability insurance.

Interested in learning more about AAS or about our positions Send our recruiter an email at or send a text/call at . We look forward to hearing from you!

Ensures the quality and safe delivery of home health services:

Completes assessments that are timely and appropriate of physical mental psychological/social (behavioral) functional financial treatment resource and spiritual needs of patients.
*Provides skilled nursing care services by planning organizing directing coordinating evaluating and documenting all aspects of nursing care in accordance with physician/APC plan of care.

Coordinates patients care through collaboration with patient/care giver multidisciplinary team and physician/APC.

Intervenes consistently and changes interventions with orders to meet changes with patient/caregiver needs.

Evaluates each visit the effectiveness of interventions and the patients response to intervention.

Provide direct patient care by assessing patient for care needs resources to meet needs and developing a home care plan of care in conjunction with physician. Assures completion of required OASIS assessments according to regulations for home care and QAPI measures.

Coordinates implementation of the plan of care through a multidisciplinary home care team community resources and physician/APC.

Ensures plan of care is followed and that documentation complies with regulatory requirements.

Maintains a department productivity standard for visits and caseload management.

Demonstrates professional accountability for self-scheduling patient case load with appropriate frequency and duration and concurrently updates schedule throughout the day as needed so that ongoing patient needs can be met.

Assure patients on case load are notified timely of their visits any unplanned schedule changes and accommodate patients preferred schedule as available.

Precepts newly hired nurses students and serves as a resource person and professional role model as needed.

Maintain communication with the multidisciplinary team s and assures that orders for necessary care plan changes are obtained and communicated timely to the team.

Initiates documentation in the home and completely records all care delivery so that receiving staff have record of care delivered in a timely manner per agency policy and procedures.

Oversight and delegation of the plan of care within the care team as appropriate to LPNs and CNAs.

Assumes professional responsibility for current nursing practice and clinical standards of care.

Participates in agency continuous quality improvement and process improvement project (PIP) activities as required.

Assume other leadership roles as required by the department.

Responsible for holiday coverage select weekend coverage and evening call for agency and patient home visits as required on a rotating basis.

Performs other functions as required.
Critical Elements of Caring Practices Performance

Caring Practices: Incorporates nursing activities that create a compassionate supportive and therapeutic environment for patients and staff with the aim of promoting comfort and healing

and preventing unnecessary suffering.

Applies The Promise and incorporates into care interactions.

Applies Exceptional Patient Experience principles and incorporates into care interactions

Applies respect and timely response in interactions with patient family health care team members

Interacts with patient and family providing compassionate non-judging empathetic care

Clinical Judgment and Action: Uses clinical reasoning which includes clinical decision-making critical thinking and a global grasp of the patient care situation coupled with nursing skills acquired through a process of integrating formal and informal experiential knowledge and evidence-based guidelines to manage patient care. Critical Elements of Clinical Judgment and Action Performance

Consistently uses the nursing process to structure and revise care.

Anticipates recognizes and responds to changes in condition

Accurately communicates with healthcare team members to relay changes in patient status

Consistently provides care based upon need and urgency

Consistently applies patient safety principles

Develops plans and evaluate patient short- and long-term care goals. Charts problems plans and goals appropriately in EMR

Consistently follows policies procedures standing order sets care bundles core measure practices.

Consistently follows red rules: Patient identification and handwashing.

Seeks consultation if uncertain on how to respond to patient needs

Adjusts care to establish and support care goals

Integrates technology into daily care of patient by appropriate initiation of technology maintenance troubleshooting and discontinuation

Consistently and accurately documents care per policies & standards

Patient Advocacy: Works on behalf of the patient/family representing their concerns and helps resolve ethical and clinical issues that impact the patient situation.

Critical Elements of Patient Advocacy Performance

Maintains patient confidentiality/personal/medical information

Identifies ethical and clinical issues

Acts with integrated healthcare team using appropriate resources to resolve ethical/clinical issues

Advocates for patient needs values and goals

Compliance with JC Rights and responsibilities of the Individual elements

Clinical Inquiry: Uses high standards and evidence-based practices along with questioning research and evaluation skills to provide informed and/or change practice Critical Elements of Clinical Inquiry Performance

Supports process/quality improvement initiatives and incorporation into practice

Follows and is informed on Department outcome measures

Actively participates in changes in practice/roll outs

Seeks advice and consultation on care from colleagues and interdisciplinary team

Collaboration: Involves multidisciplinary team as well as patient/family to promote optimal and realistic goals and outcomes

Critical Elements of Collaboration Performance

Provides and coordinates independent interdependent and dependent care interventions with interdisciplinary care team

Selects appropriate Screenings from HED to facilitate interdisciplinary care when needed

Appropriately delegates care monitoring delegated team members care and responds as appropriate with the goal of optimizing care

Interactions with care team in respectful professional manner

Facilitation of Learning: Fosters patient/family learning to promote self-care using both formal and informal processes as applicable and at an appropriate level of understanding.

Critical Elements of Facilitation of Learning Performance
Self: Completes all required learning modules programs in specified time
Self: Uses available resources within system to enhance own continuous learning
Self: sets and achieves learning and performance goals yearly
Self: Consults teaches supports continuous learning with colleagues
Self: Actively seeks learning/mentorship
Patient: Assess patients learning style readiness to learn challenges to learning and adapts Patient education to meet needs
Patient: Incorporates patient in learning about diagnosis(es) care management medications using appropriate verbal and written communication tools/resources

Response to Diversity: Uses holistic body mind spirit approach in provision of care by recognizing appreciating and incorporating cultural spiritual gender race ethnicity lifestyle socioeconomic age and value differences in practice. Critical Elements of Response to Diversity Performance
Provides communication/ medical interpretation services for population served based upon language preference
Consistently provides care to population served with appreciation to diversity elements as designated above
Consistently communicates and documents patient diversity needs

Uses PHS established internal resources and vendors

System Thinking: Manages environmental and system resources across the healthcare system and community to meet patient/family needs or provision of quality care.
Critical Elements of Systems Thinking Performance

Utilizes internal and PHS resources to provide evidence-based care including policy protocols procedures approved specialty resources

Incorporates all patient safety technology tools protocols communications and initiatives to optimize a safe patient environment

Deploy in the clinical environment processes to enhance care efficiency cost containment
Plan maneuver and deliver services/technology that are available within the system to meet the care needs of the patient

Negotiates within the system to achieve the care needs of the patient

Associate Degree in Nursing

Registered Nurse - NM

Minimum one year acute care experience within the last 3 years.

Hospice or home care experience preferred.

Basic typing competency

Must have current drivers license and auto insurance.

BLS required at time of hire

Presbyterian exists to improve the health of patients members and the communities we serve. We are a locally owned not-for-profit healthcare system comprised of nine hospitals a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908 we are the states largest private employer with nearly 13000 employees - including more than 1200 providers and nearly 3500 nurses.

Our health plan serves more than 640000 members statewide and offers Medicare Advantage Medicaid (Centennial Care) and Commercial health plans.

AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.

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