This position will assure individual patient home and hospice care discharge needs are coordinated and met in the most efficient expeditious manner, meeting regulatory requirements. Develop a discharge plan based on interdisciplinary assessments developed and implemented by the Health Care Team at the bedside. The Home Health Liaison is accountable for coordinating, facilitating and expediting the final discharge plan involving Skilled Home Care, Hospice, and Home Support services.
Participates in comprehensive discharge planning for Ridgeview Medical Center's patients. Discharge planning occurs for the purpose of promoting the patient's return, if possible, to his/her prior functional status or to an enhanced level of functioning and ability to meet ADL needs with the lowest level of support possible. Patients, families and significant others are included in the discharge planning process. Discharge plans will be updated throughout the patient's hospital stay in unit-based discharge planning reviews and interdisciplinary care conferences. Home Health Liaison will collaborate with the interdisciplinary team members to promote the best discharge plan upon the day of discharge.
The Home Health Liaison screens patients and facilitates all aspects of admission to home care, hospice, and home support services to the patient's agency of choice.
Minimum Education/Work Experience
Diploma or BS degree in nursing RN license held under the state of MN
3 years experience in home care, hospice, private duty or home infusion therapy
Ability to respond appropriately with flexibility to unpredictable situations and diverse patient populations
Ability to meet and maintain the necessary background checks as aligned with position functions
Ability to communicate in the English language for effective written and verbal correspondence in order to complete job functions as mentioned above
Comprehensive knowledge of Home Care, Hospice, Home Support and County Programs
Ability to educate physicians and staff with changes or new regulatory requirements
Demonstrated ability to develop comprehensive discharge plan as a member of the interdisciplinary health care team
Identifies patients who are at high risk when transitioning from hospital to home and would benefit from home health, hospice, home support or home medical services post discharge, reviewing insurance information as needed
Strong communication skills to communicate recommendations and provide the necessary coordination with physicians and the health care team. Including assisting physicians with the required orders
Collaborates with IV contracted service companies to understand services and rates
Other duties as assigned
MN Nursing License
Current CPR certification or certified within 1 month of hire
Public health experience; Experience in home care or hospice
Cognitive and Mental Demands
Time Awareness - ContinuousWriting - ContinuousInitiation of Work - ContinuousMemory - ContinuousReceptiveness to Change - FrequentReasoning - ContinuousRequired Sequences in Work - OccasionalProblem Solving - ContinuousAttentiveness Duration - ContinuousSocial Interactions - ContinuousMathematical Aptitude - FrequentConflict Management - FrequentReading - ContinuousDetail Oriented - Continuous
Link to Employee Health Physical DemandsAdditional InformationFTE:CasualWeekend Rotation:None at this TimeHoliday Rotation:None at this TimePrimary Shift:DayDepartment:Home Health/Hospice