Major Responsibilities:

Performs all scheduled visits and collaborates with members of the interdisciplinary team as necessary.

Conducts thorough physical, psychosocial and environmental assessments of assigned patients and updates plan of care where appropriate and as a result of visit finding.  Follows a care plan, which identifies problems (nursing diagnosis) and evaluates outcomes within a certain time frame.

Communicates with physicians to confirm and update patient's plan of treatment that may be necessary as a result of assigned visits.  Communicates those changes to the RN Case Manager.

Provides on-going assessment of patient response to treatments, medications and teaching and applies interventions as appropriate.  Updates and revises care plan as indicated.

Partners with the RN Case Manager to provide discharge planning according to agency standards and utilizes interagency/system and community resourc...