Nurse, Public Health Lead-Infusion - Now Hiring

To ensure coordination of care & services provided to all patients receiving services in the Home Infusion Program. Key functions are to develop a coordinated admission plan of care for patients referred; facilitate coordination of disciplines & services; use problem-solving & critical thinking skills to facilitate, coordinate, & execute effective, timely responses to clinical problems as they arise for patients; & facilitate transitions across the continuum of healthcare settings for all patients in the Home Infusion Program. The Home Infusion Team Leader, under the direction & in partnership w/the Home Infusion Manager & Home Infusion Supervisor provides clinical leadership for the home infusion team to enhance the delivery of timely high quality & costeffective care which meets all regulatory, accreditation, licensure & certification requirements.

Essential Functions:
- Referral & Admissions to Home Infusion: Receives & evaluates appropriateness of the home infusion referral in collaboration w/other team members (care team members, pharmacists, pharmacy technicians, supervisor, scheduler, discharge coordinators, long-term care team, exp&ed care, physicians, clinic social workers, & others as needed). Ensures timely admission based on assessment. Assess clinical implications of services ordered, patient/caregiver ability to manage self-care, requirements for clinical monitoring, vascular access, patient stability, patient behavior that could impact a safe plan of care, & other factors that could impact safety & efficacy of admission care plan. Coordinate appropriate services & interventions by obtaining appropriate initial physician orders (e.g. vascular access, wound care; wound VAC, medications, etc). Participate in the development & coordination of a comprehensive admission plan of care that incorporates an understanding of patient-specific benefits & eligibility requirements in collaboration w/care team, outpatient resources, referring physician & when appropriate, the infusion program medical director. Assure that appropriate supplies & equipment needed to provide initial services are available (e.g. IV supplies, wound supplies, wound VAC, DME, enteral pumps, glucometers, medications, etc) to meet patient needs.
- Make recommendations to modify the plan of care to expedite a safe transition of care, reduce risks, & enhance patient outcomes. Conferences w/interdisciplinary home infusion team to identify & communicate start of service to patient/caregiver based on physician orders & patient care needs. Discusses & collaborates w/referral source, home care team members, physician, discharge coordinator, supervisor & in some cases the infusion program medical director regarding complex discharges, unsafe discharge plans, & inappropriate referrals. Assists in identifying & coordinating alternative options to current care needs, which may include on-site or telephone conference w/healthcare team members & patient/family/caregivers. Advocate for the patient & family, as well as the healthcare system to optimize utilization of resources. This includes acting on behalf of the member to ensure they are informed of their financial obligations & understand their appeal rights. Coordinates referrals out to contract & non-contract providers for members that require home care services that can not be provided by agency staff within the Portland/Vancouver service area. Develop & maintain expert level of knowledge & skills related to agency policy, state practice acts, applicable state & federal regulations, utilization management, & qualifications for home care services.
- The Home Infusion Team Leader will assist in the supervision of home infusion nursing personnel by: Oversite of day-to-day staffing & patient schedules. Assists w/monitoring of staff performance, provides input into staff evaluations & documentation of performance problems to Home Infusion Supervisor & Home Infusion Manager. Leads daily Am board meeting w/Home Infusion Pharmacy staff. Assists w/interviewing process of applicants & provide hiring recommendations to Home Infusion Supervisor & Home Infusion Manager. Leads case conference/team meetings.
- Optimizes the patient's home care plan by providing: Telephone Advice/Problem-solving for patients/caregivers. Follow up to after hours advice calls. Resource, support, & advice for home care staff. Physician communication & support. Facilitates scheduling of follow up visits & procedures related to advice calls. Oversees the day to day staffing & patient schedules & problem-solves staffing challenges to meet patient needs, within staffing rules. Supply & DME ordering. Assistance w/paneling patients w/physicians. Facilitates Care Conferences (Case Conferences, IDT, Complex Discharges, etc). Coordinates care w/Home Phlebotomy. Conducts Medication Reconciliation for Therapy only cases. Reviews & approves Home Health Aide Care Plans for Therapy only cases.
- Coordinate, expedite, & track referrals & transitions across care settings (e.g. home phlebotomy referrals, wound program referrals, transfers to inpatient, transfers to ICF/SNF, respites, & across home care programs). Acts as Kaiser Permanente ambassador to provide member information to care facilities (SNF/ICF, assisted living, adult foster care home, & residential care facilities) & problem-solve/facilitate any issues which present barriers to safe transfers & the provision of quality care (e.g. Special equipment needs, symptom/behavior management, financial assessment & plan, clinical instability, & complex care needs.
- Provide education & program development functions: Ensures systematic & on-going contact w/hospital staff & other Kaiser Permanente Departments (e.g. LTC, Expanded Care, DME, Hospital Care Coordinators, Clinic Social Workers, Clinic Case Managers, Pharmacy, Home Health & Hospice Program, Membership Services, etc) to share information & ensure safe transitions of care. Provides education to staff to expedite safe transitions of patients across care settings. Participates in orientation of staff to the department. Ensure appropriate & timely care to patients through collaboration w/inpatient staff, CCS home care staff, & outside resource staff. Makes home visits w/Home Infusion Nurses to assure employees providing home infusion care have knowledge & skills required to provide age appropriate care to patients & families through education, training or experience. Provides mentoring & coaching, & input into staff evaluations & documentation of performance problems to Clinical Supervisor. Participates in professional committees & task forces as needed/requested. Ensure regulatory & compliance st&ards are met in collaboration w/others in the inter-disciplinary health care team. Participates in quality & utilization management activities (e.g. Chart audits). Participates in continuing education to incorporate & maintain up to date knowledge & best practices in home infusion & home health.
- Provides expert practice consultation for the home infusion team, CCS outpatient & skilled nursing facility staff. Assures professional competency through maintaining state of the art skills & knowledge consistent w/Medicare & JCAHO regulations, applicable nurse practice acts & agency policies.
- Conducts patient home visits as required to assist the program in meeting patient needs. Participate in program call duty as needed. Performs other duties as assigned.