JOB DESCRIPTION FOR JOB TITLE:



|RN – Home Health Revisit |

|Job Code: 800014 |FLSA Status: Non Exempt |Mgt. Approval: |Date: 6-2014 |

|Department : 93820 Home Health |HR Approval: DPS |Date: 6-2014 |

|JOB SUMMARY |

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|The Home Health Revisit Nurse works in association with team of nurses (which may include primary nurses, per diem nurses, and LPN’s) to deliver care with a group of |

|patients and families in a particular geographic area. Through direction from the Home Health Triage/Scheduler Nurse, and/or the Nurse Manager, the Home Health Revisit|

|Nurse performs direct patient and family care in the home, with a goal of achieving excellent patient care outcomes and providing caregiver continuity. The Home Health|

|Revisit Nurse has on-call responsibilities and reports to the Nurse Manager. |

|Clinical responsibilities include: |

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|Provides comprehensive nursing assessment, planning, implementation and evaluation to an assigned group of home health patients and families within the scope of her/his|

|license and as ordered by a physician. |

|Identifies the educational needs with home care patients and families and assists in the development of resources to meet those needs. |

|Communicates with physicians and other health professionals to coordinate home health services. |

|Awareness of community resources and ability to make appropriate referrals. |

|Working knowledge of home care regulations and third party reimbursement principles. |

|Functions as a positive role model, and occasionally as a mentor for professional nursing and allied health students. |

|Contributes to and supports the effective operation of UWHH. |

|Works effectively with interdisciplinary professional and support personnel who provide care with patients and their families in the community. |

|Demonstrates initiative for the professional development of self, clinicians and other UWHH staff. |

|Participates in assigned performance improvement and research activities, with a goal of maintaining appropriate standards of care and improved patient outcomes. |

|MAJOR RESPONSIBILITIES |

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|The Home Health Revisit Nurse performs his/her job demonstrating technical ability, understanding of job expectations and compliance with organizational policies and |

|procedures. The incumbent performs the following job responsibilities: |

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|The Home Health Revisit Nurse provides comprehensive assessment, planning, implementation and evaluation with home care patients and families as directed by the |

|Scheduler/Triage Nurse and/or Nurse Manager and in consultation with the Home Health Primary Nurse. |

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|Establishes an in-depth data base by assessing the physiologic and psychosocial status with the patient and family utilizing interview, observation, physical |

|examination and other available data. |

|Assesses the home environment for safety, infection control, and community resource needs. |

|Collects information for assessment from the patient, family, physician and other health care team members. Incorporates multi disciplinary data into the nursing |

|assessment of each home care patient. |

|Sets priorities and applies previous nursing experience and base of knowledge, adapting with the patient and family in a home setting. Plans with patient, family and |

|physician for care which is feasible within the physical, financial and emotional resources of the family. |

|Establishes individualized, measurable goals in consultation with the patient, family and other health care providers in order to achieve appropriate home health |

|standards of care and patient outcomes; evaluates progress toward established goals. |

|Assumes responsibility and accountability for effectively managing nursing care of patients as assigned by the home health primary nurse, triage/scheduler nurse, or |

|nurse manager. |

|Implements safe, competent and efficient skilled nursing care based on UW Home Health policies, procedures, and standards of care. |

|Maintains technical skills according to UWHH standards, as measured by competency assessments during orientation and annually. |

|Documents the nursing process to reflect a comprehensive and integrated approach to home health care. |

|Evaluates the home care patient's response to care based on a continuing assessment and analysis of the needed interventions. Initiates change in the patient's plan of|

|care based on this evaluation. |

|In response to information indicating urgent and/or emergent risk with the home care patient, notifies the physician and nurse manager immediately with the action |

|taken. |

|Uses equipment and supplies in an efficient and cost effective manner. |

|Accurately follows established infection control and safety policy and procedure. |

|Assesses for presence of advance directives and facilitates further action in obtaining information about or implementing advance directives if indicated. |

|Demonstrates knowledge of the health care delivery system as a multi disciplinary, multifaceted entity with a variety of entry and access points along the care |

|continuum. (inpatient, clinic, home health, and extended-care facility. |

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|Patient, family, and caregiver education: |

|Identifies learning needs with patient/family and teaches by adapting standard information to provide individualized and comprehensive teaching and learning. Utilizes |

|resources of the UWHC Teaching-Learning Center and UWHH to meet identified patient, family and/or caregiver needs. |

|Involves the individual home health patient/family in identification of requirements or perceptions of learning needs to promote a self-care philosophy. |

|Follows an established teaching plan efficiently, expanding on existing knowledge base and skills of patient/family/caregiver, and identifying logical next steps to |

|further the teaching plan toward established goals. |

|Teaches the home care patient/family and other care provider critical knowledge and skills necessary to accomplish the self-care regimes in order to manage ongoing |

|health care needs. |

|Ensures that the home care patient and family demonstrate their knowledge (within their abilities) of home care rights/responsibilities, diagnosis, health care status, |

|treatments, skills, medication regime, advance directives and adaptive behaviors gained as a result of teaching interventions. |

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|The Home Health Revisit Nurse must possess excellent communication skills, both written and verbal. |

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|Documentation |

|Documents information which leads to insights or the solution of usual home care patient problems, the response to, and the outcome of care provided. |

|Documents in the computerized medical record in accordance with UWHH policies and procedures, home care regulations, and third party insurance requirements. |

|Maintains a complete record for the care that is given the patient. |

|Documentation of revisits, care coordination/phone calls, and verbal orders is accurate and timely. |

|Updates care plans, medication records, progress toward goals and other aspects of clinical record accurately and timely. |

|Accesses updated clinical record information in UWHC system and home health agency computerized medical record applications to ensure full awareness of the patient’s |

|clinical background. |

|Completes admission documentation accurately on the day of the admission. |

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|Verbal/non-verbal communication |

|Provides honest, direct, respectful communication to peers, colleagues, patients, families, and caregivers. |

|Gives feedback appropriately and remains open to feedback from others. |

|Communicates (through words and actions) an understanding of patient, family, and caregiver’s feelings and reactions to the illness state. |

|Recognizes and demonstrates congruence between verbal and non-verbal behavior. |

|Sensitive to verbal and non-verbal communication cues. |

|Develops, maintains, and terminates therapeutic relationships with patients, families, and caregivers. |

|Identifies personal strengths and areas for improvement as a communicator. |

|Demonstrates effective listening behavior. |

|Able to modify speaking style to fit the context of the situation. |

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|The Home Health Revisit Nurse must demonstrate professionalism, commitment, initiative, and leadership. |

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|Education |

|Education – Students |

|Acts as a role model for professional nursing and allied health students, accompanying them on home visits as assigned. |

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|Education – Self |

|Pursues knowledge and education that enhances professional practice. |

|Identifies learning needs and assumes responsibility for meeting own learning needs using formal and informal resources. |

|Seeks supervision of performance when appropriate. |

|Evaluates and plans own professional growth in relation to expectations for home care nursing practice. |

|Attends at least 75% of inservices, nurse’s meetings, staff development programs, and staff meetings. |

|Maintains UWHC/UWHH mandatory education requirements. |

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|Education – Peers |

|Assists in creating a positive environment conducive to learning. |

|Participates in orientation of new staff, particularly revisit nurse staff. |

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|Leadership |

|Demonstrates accountability for own practice. |

|Rotates through a cycle for providing on-call coverage during hours when agency is closed. (4:30 PM – 8 AM weekdays, and all day Saturdays, Sundays, and holidays.) |

|Ensures thorough awareness of and responsibility for the each home care patient’s total plan of care; familiarizing self with pertinent aspects of the medical record |

|before visiting unfamiliar patients to ensure seamless continuity of care among UWHH care providers. |

|Evaluates own performance in relation to home care standards of practice |

|Participates in the professional development of UWHH and the UWHC Department of Nursing. |

|Participates in the development of program goals and evaluates progress toward goal achievement. |

|Participates in committees/meetings as delegated or appointed. |

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|Productivity and Efficiency |

|Maintains productivity according to agency standards after first 3 months of employment. |

|Provides care in a geographically logical manner by reading and updating directions to home in the medical record and effectively using map-reading skills. |

|Facilitates cost control in scheduling home visits according to geographic location. |

|Uses technology effectively to support nursing practice and create efficiencies in care delivery. |

|5. Exhibits effective time management, organization, and prioritization skills |

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|The Home Health Revisit Nurse must exhibit teamwork by collaborating with individuals and groups to establish and attain common goals: Contributes to and supports the |

|effective operation of UWHH. |

|Collaborates with interdisciplinary professional and support personnel to positively impact the outcomes of health care provided to the patient and their family in the |

|community. |

|Attends and participates in team meetings regularly. |

|Participates in scheduling processes as part of a geographically-oriented team of caregivers, with a goal of enhancing caregiver continuity and care outcomes for |

|patients and caregivers. |

|Delegates and supervises in accordance with the Wisconsin Nurse Practice Acts and the professional nursing role, including development of aide care plans and |

|supervision of home health aides and LPNs. |

|Initiates steps to support and enhance the patient's responsibility and self-determination in decision-making related to health status, treatment options and |

|well-being. |

|Demonstrates flexibility in adjusting assignments to meet staffing and scheduling needs. |

|Maintains an updated schedule in the office, checks schedule for changes regularly, and communicates scheduling changes to the office promptly. |

|Maintains consistent availability throughout the work day, responding to UWHH office communications via Email, voice mail, and pager within expected timelines. |

|Demonstrates effective strategies in managing stress and resolving conflict. |

|Participates and supports others in group decision-making. |

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|The Home Health Revisit Nurse must deliver excellent customer service. S/he must recognize and respect the values of self and others: Customer Service |

|Introduces self and addresses patient, family and caregivers by preferred name. |

|Exhibits awareness and respect for the patient and family home or home-like setting as a care environment. |

|Treats all persons with respect and dignity. |

|Understands own behavior and how it affects other people. |

|Notifies patient/family/caregiver by 9 AM of the expected time for that day’s visits. |

|Understands and attempts to meet the needs, wants, and expectations of internal and external customers. |

|Addresses concerns or complaints voiced by patients, families, caregivers, or other internal and external customers, and notifies manager. |

|Displays professional attitudes and behaviors of trust, respect, honesty and caring. Enables co-workers, patients and families to verbalize their needs for assistance.|

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|Values: Recognizes and respects the values of self and others, demonstrating that recognition and respect in a holistic and caring manner. |

|Demonstrates understanding of differences in cultural, spiritual, and socioeconomic backgrounds. |

|Able to recognize differences between values of self and others, and administers care impartially regardless of the differences. |

|Identifies ethical conflicts and notifies manager, then participates in related problem solving. |

|Able to identify resources and options for addressing ethical issues and usual agency pattern, including involvement of the manager, primary physician, and social |

|services. |

|Involves the patient/family in the plan of care, incorporating their cultural, spiritual and other belief systems. |

|Recognizes the importance of respecting individual patient and family choices regarding care and treatment options. |

|Maintains patient privacy and confidentiality. |

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|The Home Health Revisit Nurse is committed to performance improvement and problem solving. |

|Aware of and participates in current performance improvement activities at UWHH, exhibiting effective problem solving skills on an individual basis with each patient |

|situation, and on an overall basis within the UWHH agency. |

|Assists leadership in identifying potential clinical practice issues and contributes to the development of specific plans to improve home care patient outcomes. |

|Demonstrates knowledge of research findings related to home health nursing by implementing current practice standards. |

|Incorporates changes in clinical practice to reflect new advances and ensure effectiveness of planned interventions. |

|Utilizes UWHH and UWHC resources to problem solve new or unfamiliar patient situations. |

|Utilizes UWHH and UWHC Department of Nursing resources (pain resource nurses, wound resource nurse, UWHC advanced practice nurses) to improve quality and outcomes of |

|patient care. |

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|ALL DUTIES AND REQUIREMENTS MUST BE PERFORMED CONSISTENT WITH THE UW HEALTH PERFORMANCE STANDARDS. |

|JOB REQUIREMENTS |

|Education |Minimum | |

| |Preferred |BSN |

|Work Experience |Minimum |One (1) year of relevant Clinical RN experience in medical/surgical nursing and/or home health nursing with a |

| | |Medicare-certified home health agency. |

| |Preferred |Two (2) years of recent home health nursing experience with a Medicare-certified home health agency. |

|Licenses & Certifications |Minimum |Registration as a professional nurse in the State of Wisconsin. |

| | |Valid Wisconsin driver’s license and current auto insurance. |

| | |CPR certified |

| |Preferred |      |

|Required Skills, Knowledge, and Abilities |1. Knowledge of home care regulations and third party reimbursement as it impacts the delivery of patient care|

| |services. |

| |2. Experience in teaching both patient and families self-care skills. |

| |3. Current IV therapy skills with knowledge of venous access devices. |

| |4. Knowledge regarding the impact of acute and chronic illness on the lives of patients and families in the |

| |home. |

|AGE SPECIFIC COMPETENCY (Clinical jobs only) |

|Identify age-specific competencies for direct and indirect patient care providers who regularly assess, manage and treat patients. |

|Instructions: Indicate the age groups of patients served either by direct or indirect patient care by checking the appropriate boxes below. Next, |

|x |Infants (Birth – 11 months) |x |Adolescent (13 – 19 years) |

|x |Toddlers (1 – 3 years) |x |Young Adult (20 – 40 years) |

|x |Preschool (4 – 5 years) |x |Middle Adult (41 – 65 years) |

|x |School Age (6 – 12 years) |x |Older Adult (Over 65 years) |

|JOB FUNCTIONS |

|Review the employee’s job description and identify each essential function that is performed differently based on the age group of the patient. |

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|PHYSICAL REQUIREMENTS |

|Indicate the appropriate physical requirements of this job in the course of a shift. Note: reasonable accommodations may be made available for individuals with |

|disabilities to perform the essential functions of this position. |

|Physical Demand Level |Occasional |Frequent |Constant |

| |Up to 33% of the time |34%-66% of the time |67%-100% of the time |

| |Sedentary: Ability to lift up to 10 pounds maximum and occasionally |Up to 10# |Negligible |Negligible |

| |lifting and/or carrying such articles as dockets, ledgers and small | | | |

| |tools. Although a sedentary job is defined as one, which involves | | | |

| |sitting, a certain amount of walking and standing is often necessary | | | |

| |in carrying out job duties. Jobs are sedentary if walking and | | | |

| |standing are required only occasionally and other sedentary criteria | | | |

| |are met. | | | |

| |Light: Ability to lift up to 20 pounds maximum with frequent lifting |Up to 20# |Up to 10# or requires |Negligible or constant |

| |and/or carrying of objects weighing up to 10 pounds.  Even though the | |significant walking or |push/pull of items of |

| |weight lifted may only be a negligible amount, a job is in this | |standing, or requires |negligible weight |

| |category when it requires walking or standing to a significant degree.| |pushing/pulling of arm/leg | |

| | | |controls | |

|x |Medium: Ability to lift up to 50 pounds maximum with frequent |20-50# |10-25# |Negligible-10# |

| |lifting/and or carrying objects weighing up to 25 pounds. | | | |

| |Heavy: Ability to lift up to 100 pounds maximum with frequent lifting |50-100# |25-50# |10-20# |

| |and/or carrying objects weighing up to 50 pounds. | | | |

| |Very Heavy: Ability to lift over 100 pounds with frequent lifting |Over 100# |Over 50# |Over 20# |

| |and/or carrying objects weighing over 50 pounds. | | | |

|List any other physical requirements or bona fide occupational qualifications:| |

Note: The purpose of this document is to describe the general nature and level of work performed by personnel so classified; it is not intended to serve as an inclusive list of all responsibilities associated with this position.

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