Major Responsibilities:

Uses the nursing process to assess the needs of the patient, plan and implement individualized interventions in the home and evaluate the effectiveness of the plan of care through twice daily visits with the patient. Includes the patient and family in planning and implementing care and develops and maintains a therapeutic relationship throughout the healthcare continuum.Anticipates and recognizes significant changes in the patient’s condition, status, and need for care escalation that may be needed in the in-home care setting. Provides in home assessment of the patient and takes appropriate actions when changes occur. Anticipates and alters the plan of care as needed, mobilizes appropriate resources, and collaborates with other health care team members to coordinate patient centered care. Implements strategies to reduce patient risk and increase patient safety while in the home.Actively coordinates the discharge plan utilizing an interdisciplinary approach. Applies evidence-based practice to deliver patient care in the home. Consistently incorporates nursing and regulatory standards of care into practice.Provides ongoing in-home evaluation of patient, team, and unit outcomes and is empowered to take appropriate action when changes are needed while providing care in the home. Supports shared governance activities and initiatives to improve processes and patient outcomes.Demonstrates effective communication and promotes collaboration among healthcare team members virtually and in-person. Assumes a leadership role in the care team and delegates appropriately to unlicensed personnel.Promotes a culture of safety through identifying threats to patient and in-home care team’s safety and intervening to prevent harm. Reports patient safety events and near misses in a timely manner. Seeks to identify potential safety issues and assists in the implementation of corrective actions.Applies ethical decision making, demonstrates respect and understanding for peers, and other clinical disciplines. Participates as an effective member of the patient care team while working in the home to formulate an integrated, unbiased, individualized approach to care.Participates in quality/process improvement initiatives to improve the functions of the department and the in-home patient care experience.Participates in professional activities which contribute to personal professional development and the development of others. Seeks opportunities to be taught, coached, and mentored. Attends required meetings/educational programs and completes annual competencies in a timely manner.Must be able to demonstrate knowledge and skills necessary to provide in-home care appropriate to the age of the patients served. Must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify each patient's requirements relative to his/her age-specific needs, and to provide the care needed as described in the department's policies and procedures. Age-specific information is developed further in the departmental job standards.

Licensure, Registration, and/or Certification Required:

Registered Nurse license issued by the state in which the team member practicesBasic Life Support (BLS) for Healthcare Providers certification issued by the American Heart Association (AHA).Required to have a valid driver’s license issued by the Division of Motor Vehicles and acceptable vehicle operator recordTravel required within designated geographic area

Education Required:

Completion of an accredited or approved program in Nursing.

Experience Required:

Minimum of two-years of recent nursing experience in an acute bedside setting or emergency nursing

Knowledge, Skills & Abilities Required:

Demonstrates progression to provide holistic patient care in the home and the ability to view clinical situations from a patient and family focus.Demonstrates progression to recognize situational changes while providing care in the home that requires unplanned or unanticipated interventions, and responds to situations with confidence, timeliness and flexibility.Proficient technology skills, use of electronic mail, electronic medical records systems, and remote patient monitoring equipmentExcellent communication (written and verbal), listening and interpersonal skills.Ability to work independently while in the patient’s home in collaboration with the virtual care team.Provides comprehensive nursing assessment in an untraditional nursing environment.Demonstrates human relation skills with the ability to develop rapport and maintain positive, professional relationships with a variety of patients, team members and physicians while providing care in the home. Ability to take initiative and work collaboratively with others.Demonstrated ability to effectively make critical, independent decisions.Excellent organization, prioritization and problem-solving skills.Demonstrates time management skills with an ability to multi-task and prioritize in an environment with frequent interruptions.Demonstrates coordination, collaboration, delegation and team building skills.

Certification Addendum:

Team members will maintain annual educational requirements for hospital based certifications (e.g. DNV, CARF or others)

Physical Requirements and Working Conditions:

Must be able to sit, stand, walk, lift, squat, bend, reach above shoulders, and twist frequently throughout the workday in possible confined spaces.Must be able to work safely with people of various sizes and weight with diverse and complex medical conditions and physical limitations.Must be able to:lift up to 50 lbs. from floor to waist.lift up to 20 lbs. over the head.carry up to 40 lbs. a reasonable distance.Must be able to:push/pull with 30 lbs. of force.May be exposed to chemical and hazardous waste as well as blood and body fluids and communicable disease. Therefore, protective clothing and equipment must be worn as necessary.Must have functional speech, vision, hearing, and touch with ability to use fine hand manipulation skills for IV insertion and other procedures/functions.Operates all equipment necessary to perform the job.Work environment includes probability of exposure to adverse, hazardous, or unpleasant conditions while caring for the sickMust be able to travel to all areas within the Advocate service area in all extremes of weather on all types of roadsMust have a tolerance for differences and an appreciation of multi-culturalism and diversity of the patients and their families.Required to make visits to private residences which may not be accessible to people with disabilities. This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.