Job Description
Home Visits
Conducts face-to-face visits with patient in healthcare facilities and in patients' homes.
Initiates telephone outreach and is available by phone during office and on-call hours
Works independently and keeps physicians informed of patient status.
Uses all components of the Transitional Care Model and nursing process including assessment, triage, planning, implementing, and evaluating care to meet the patients' needs.
Collects, organizes, documents, and analyzes data, synthesizing it into understandable information
Coordinates continuity of care, prevention and avoidance of complications, and close clinical treatment and management under the direction of the patient's primary healthcare provider(s).
Effectively communicates, problem-solves, and maintains productive and effective interpersonal relationships while effectively prioritizing.
Works with outside facilities and agencies on a routine basis, maintaining positive working relationships.
Supports patients and their families, and provides compassionate care
Provides training, oversight, and supervision of assigned TCN-RNs, conducting new-hire orientations, performance evaluations, reviewing patient satisfaction surveys, and reporting back to Director of Nursing and Medical Director.
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