Presbyterian Complete Care is seeking a dedicated and skilled healthcare professional to provide acute and routine home visits, delivering comprehensive clinical care to patients in need. This role requires conducting thorough head-to-toe assessments, monitoring vital signs, evaluating symptoms, and performing specialized procedures such as wound care, Foley catheter maintenance, electrocardiograms (EKGs), and laboratory specimen collection. In addition to providing clinical care for both acute and chronic conditions, the nurse will ensure proper medical device functionality and address any complications that arise. Patient education is a key component, ensuring individuals understand their care plans, medication management, and lifestyle adjustments to support improved health outcomes. Strict adherence to infection control protocols and precise implementation of provider-directed care plans are essential. Furthermore, this position involves active collaboration with interdisciplinary teams to ensure coordinated, patient-centered care, utilizing secure communication channels such as Epic’s secure chat to provide real-time updates and consultations. Participation in care plan discussions is vital to facilitating optimal patient outcomes, allowing for necessary adjustments based on clinical evaluations. Additionally, PRN support will be provided for both the Hospital at Home and PAC-P programs as needed. If you are passionate about delivering high-quality care in a home setting and working collaboratively within a healthcare team, we encourage you to apply for this rewarding opportunity.
Type of Opportunity: Full Time FTE: 1.0 (40 Hours per week)
Work Schedule: Monday - Friday 8 Hour Days
Sign on and relocation bonuses available for qualified candidates.
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Demonstrates nursing care management of patients as evidence by
a. Assessments that are complete, timely, and appropriate of physical, mental, psychological/social (behavioral), functional, financial, treatment, resource and spiritual needs of patients.
b. Analysis that defines problems that are capable of correction through home healthcare and hospice interventions and are prioritized in development of care plan.
c. Intervenes consistently with orders and changes interventions with orders to meet changes in patient need
d. Evaluates each visit the effectiveness of interventions and the patients response to intervention.
Provide direct patient care by assessing patient for care needs, resources to meet needs and developing a home care or hospice plan of care in conjunction with physician.
Coordinates implementation of the plan of care through a multidisciplinary home care or hospice team, community resources and the physician
Ensures plan of care is followed and that documentation complies with regulation.
Maintains a department productivity standard for visits and caseload management.
Demonstrates professional accountability for self-scheduling patient case load with appropriate frequency and duration, and concurrently updates schedule throughout the day as needed so that ongoing patient needs can be met.
Assure patients on case load are notified timely of their visits and of any unplanned schedule changes accommodating, when possible, patent preferences for time of day.
Precepts newly hired nurses, and students and serves as a resource person and professional role model as needed.
Maintain communication with the multidisciplinary team s and assures that orders for necessary care plan changes are obtained and assures that changes are communicated timely to the team.
Initiates documentation in the home and completely records all care delivery so that receiving staff have record of care delivered by the end of each day which includes admissions.
Demonstrates proficiency and competency in interventions (treatments) required through day to day practice and annual competency testing.
Delegate or assign aspects of patient care to health care team members commensurate with their validated competency to perform the task.
Be professionally responsible for current nursing research, current nursing standards, home care or hospice philosophy in order to maintain quality.
Be responsible for clinical supervision of licensed and non-licensed assistive personnel.
Participates in agency continuous quality improvement activities as required.
Assume other leadership roles as required by the department.
Responsible for weekend and holiday coverage and evening call for agency and patient home visits as required on a rotating basis.
Assure clinical outcomes are met and sustained .
Performs other functions as required.
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About Presbyterian Healthcare Services
Presbyterian exists to improve the health of patients, members and the communities we serve. We are a locally owned, not-for-profit healthcare system comprised of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 13,000 employees - including more than 1,200 providers and nearly 3,500 nurses.
Our health plan serves more than 640,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans.
AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.
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