RN Transition Coor-Henry Ford at Home

PRINCIPLE DUTIES AND RESPONSIBILITIES

Independently participates in the clinical assessment, problem identification, and planning functions for patients who have been identified by the case management team, other health care facility personnel, physicians, or patients/families as possibly needing Henry Ford at Home products and services
2. Uses clinical assessment skills to determine the patient’s appropriateness for Henry Ford at Home services by reviewing the patient’s medical condition as well as the patient’s and caregiver’s potential ability to assist with aspects of the care plan, performing an assessment identifying required community services, and communicating the needs with the physician and other appropriate individuals.
3. Collaborates and communicates with Henry Ford at Home leaders and staff to ensure appropriate and timely referrals. Performs patient and family education prior to start of care; provides information and education to patients and families prior to discharge
4. Interprets diagnostic data and incorporates data into the assessment. Assess health problems/perceptions of the client and or family and client’s expectations
5. Collaborates with referral sources to identify problems and resolutions
6. Coordinates patient discharge with hospital/facility case managers, including patient and/or family and other members of the health care team
7. Determines appropriate frequency of nursing visits/duration based on patient needs 
when applicable
8. Reviews and remains updated on knowledge of Henry Ford at Home criteria, 
9. Medicare conditions of participation, 3rd party payer information and CHAP guidelines.
10.Acts as a consultant and subject matter expert to the health care facility staff, patients, caregivers and the community for information regarding various aspects of Henry Ford at Home products and services.

CERTIFICATIONS/LICENSURES REQUIRED

* Registered Nurse in the State of Michigan