RN Continuous Care

SUMMARY
The RN-Continuous Care, will provide patient care as identified in the Plan of Care, developed by the home care RN or as directed by the Care Access Operations Manager, Care Access PM/NOC Supervisor or Team Manager on-call for continuous care patients or other Agrace patients in Homecare. The RN-Continuous Care will provide short-term care for an individual and their family/caregivers in a home or facility where intensive skilled nursing care is needed to control patient symptoms, such as severe pain, breathing difficulties or other urgent or complex health problems. Continuous Care patients have a detailed care plan that defines the interventions needed during acute care.

ESSENTIAL FUNCTIONS
1. Patient and Family Assessments (Percentage of time: 40%)
a. Assess patient’s and family’s physical, pain, psychosocial, emotional, spiritual, environmental and educational needs as outlined by the plan of care (POC).
b. Apply pain and other symptom management expertise according to Agrace standards, policies and practices; use pain/symptom management skills to aggressively intervene at time of pain crisis or exacerbation of other symptoms.
Job Title: Registered Nurse (RN)-Continuous Care
Department: Homecare/After-Hours Homeca
Reports to: PM/NOC Supervisor/Care Access Operations Manager
Manages Others: Yes No
c. Collect data from the patient, family, significant other or other members of the interdisciplinary team and other health care professionals.
d. Identify, interpret, and document assessment data collected in the nursing interview, physical assessment and other health data.
e. Document and report significant changes in condition or unusual incidents to appropriate IDT member such as client abuse/neglect, suicidal intent, harmful coping mechanisms or violence, etc.

2. Patient Visits for Continuous Care and Focused Needs (percentage of time 40%)
a. Respond to patient and family needs or change in condition or need for acute patient intervention.
b. Provide interventions, treatments, and pain management to patient to meet needs. Evaluate the effectiveness of pain management or other intervention and adjust to meet needs.
c. Provide patient and family education on pain, symptom management, end of life, etc. Evaluate the effectiveness of education and adjust to meet needs.

3. Plan of Care (percentage of time 10%)
a. Read, understand, update, and follow the POC. Document interventions, outcomes, and changes in patient condition in electronic health record (EHR).
b. Delegate visits and make referrals to appropriate disciplines and volunteers.
c. Oversee work of Certified Nursing Assistants (CNA) and Licensed Practical Nurses (LPN).

4. Miscellaneous (Percentage of Time 10%)
a. Participate in meetings to plan and evaluate patient/family services.
b. Precept new staff and students.

The above are not to be construed as exclusive or all-inclusive. Other duties may be required and assigned.

EDUCATION & LICENSURE
1. ADN, required; BSN, preferred
2. Current, unrestricted Registered Nursing License in state of employment
3. One-year nursing experience, preferred
4. Valid driver’s license, auto insurance, and access to a reliable vehicle

KNOWLEDGE, SKILLS AND ABILITIES
1. Ability to develop, maintain, and apply knowledge of hospice and end of life process
2. Ability to maintain professional boundaries with patients, families and co-workers
3. Ability to create and follow plans of care, and patient, family, and clinical staff directions 4. Basic Microsoft Office skills
5. Intermediate electronic health records skills; Epic preferred
6. Ability to work effectively and cooperatively with others
7. Ability to communicate effectively verbally and in writing
8. Ability to be flexible in time and task to meet organizational needs
9. Ability to maintain confidentiality about patients, families, caregivers, staff, donors, and organizational intellectual property
10. Ability to use proper body mechanics, safe patient handling, and standard precautions

PHYSICAL DEMANDS
Medium work – Exerting up to 50 pounds of force occasionally with frequent lifting and/or carrying of objects weighing up to 25 pounds.

ENVIRONMENTAL DEMANDS
OSHA Categories
Category I: Duties performed routinely require exposure to blood, body fluid and tissue.

Other Environmental Demands
Duties are performed in client homes and may include exposure to clients' health conditions, some unpleasant sights, smells, contagious diseases, moderate noise levels, and some temperature fluctuations.