Under the supervision of the Home Health Director of Operations or designee, the Weekend Care Manager is responsible for assessing, coordinating and implementing care and services for all patients as assigned. The Weekend Care Manager makes all weekend nursing visits and holidays on a rotating basis. The Weekend Care Manager bridges the care and coordination of services provided to patients by Primary Care Case Managers on weekdays.
EDUCATION:
Graduate of an accredited Nursing Program required.
WORK EXPERIENCE:
Minimum of two (2) years experience as a Registered Nurse in a home health setting required.
Supervisory experience preferred.
Nursing
- Assesses, coordinates, and implements care and services for all patients assigned, in the patient’s home.
- Performs required nursing visits per patient need and/or the plan of care.
- Implements orders for medications and treatments as prescribed by the physician and all aspects of the nursing care plan.
- Reviews medication list for drug interactions and contraindications and notifies physician of any identified interactions or contraindications.
- Initiates and applies appropriate preventative, therapeutic and rehabilitative nursing procedures in accordance with physician orders.
- Reports vital sign alerts to the physician in a timely manner. Initiates additional physician orders as needed and implements appropriate interventions.
- Reviews and follows up on lab work in a timely manner and documents follow up activities.
- Provides thorough instruction and disease management education to patients and/or caregivers as ordered by the physician. Educates patients, families, and caregivers about disease process and recommended self care.
- Ensures that all patients and/or their caregivers understand their rights and responsibilities and addresses patient/family concerns.
- Ensures appropriate discharge planning.
Case Management
- Develops and/or modifies patient’s plans of care to reflect patient needs (involving patients and families as appropriate) after all visits.
Assumes primary care case management of patient’s entire episode of care if the patient only requires weekend visits. (Otherwise, communicates patient’s plan of care to Care Team Manager for assignment of patient to Primary Care Case Manager.). This includes:
- Conferences with primary physician, and all involved disciplines as needed (via email, phone as appropriate).
- Is responsible for the efficient and effective completion of the
- patient’s episode of care.
When not assuming primary case management role, communicates patient assessments, changes, and other pertinent information to the Primary Care Manager on or before the Monday morning weekend hand off.
Communicates and coordinates required weekend visits from other disciplines as per development/change of the patient’s plan of care.
- Participates in patient care conferences as requested.
- Prior to patient case conferences, develops individual nursing plans of care to reflect current patient needs, involving patients and families as appropriate.
Documentation
- Accurately completes OASIS assessment information and develops patient care plans within 24-48 hours of admission.
- Completes all other documentation accurately within 24 hours of visit, phone call, and/or change in treatment orders.
- Maintains a current medication list in the patient medical record.
- Reviews documentation with Care Team Manager as requested.
Coordination
- Works with Care Team Manager to develop weekend schedule.
On Call
- Responsible for on-call duties on a rotating basis for holidays and upon request from agency
Other
- Attends and participates in in-service training programs, team conferences, and other workshops as assigned.
- Maintains current knowledge base and nursing skills through continuing education activities and/or in-service classes.
- Follows agency policies and procedures when performing job duties.
- Participates in clinical record audits, quality monitoring activities, and patient outcome improvement initiatives as required.
Required Skills
Required Experience