Registered Nurse Home Care

The Home Care Registered Nurse provides skilled nursing care, case management, and hospice support to patients in their homes, ensuring quality care in accordance with evidence-based practices and regulatory standards. This role involves comprehensive patient assessments, development and implementation of individualized care plans, collaboration with interdisciplinary teams, and meticulous documentation to support patient outcomes and agency compliance. The nurse serves as a case manager, advocates for patient needs, and maintains up-to-date clinical skills including advanced wound care and IV management. Responsibilities:

• Complete OASIS documentation timely and accurately following agency and regulatory guidelines.
• Assess patient and caregiver needs utilizing the nursing process to provide quality care.
• Develop, communicate, and update realistic patient care plans involving patients and caregivers.
• Serve as case manager, managing caseloads and visit times per agency productivity standards.
• Implement medical plans of care, nursing interventions, and procedures ensuring patient safety and quality.
• Maintain proficiency in high-tech nursing skills such as IV use, wound VAC, and complex wound care.
• Collaborate with LPNs to delegate tasks and ensure adherence to the plan of care.
• Evaluate patient responses and outcomes to adjust care plans as needed.
• Maintain accurate and up-to-date documentation to support care continuity and regulatory compliance.
• Follow agency protocols for electronic health record processes including visit documentation and follow-up notes.
• Provide patient and caregiver education on medication, treatments, discharge instructions, and reportable conditions.
• Identify and communicate interdisciplinary needs, coordinating with physical therapy, social work, and other services.
• Complete required agency, state, and federal forms accurately and timely.
• Manage time effectively during patient visits and communicate scheduling needs promptly.
• Assess and coordinate Home Care Aide services as needed, providing ongoing supervision.
• Report patient incidents to Quality Improvement specialists in a timely manner.
• Coordinate safe patient discharges and transfers ensuring all documentation is processed correctly.
• Collaborate with physicians, providers, vendors, and team members to support patient care plans.
• Participate in monthly peer review audits and provide/receive constructive feedback professionally.
• Schedule and facilitate case conferences to optimize communication and documentation.
• Advocate proactively for patient care needs ensuring sensitivity to individual patient and family circumstances.

• Active Registered Nurse license valid in the state of practice.
• Minimum of 2 years nursing experience in hospital, home health, or hospice care.
• Strong clinical assessment, medication administration, and treatment planning skills.
• Proficiency in interdisciplinary team collaboration and effective communication.
• Bachelor's degree in Nursing or related field.
• Driver's license, car insurance, and access to an automobile for field work.

• Experience with high-tech nursing skills including IV therapy, wound VAC, and complex wound care.
• Knowledge of McKesson electronic health record systems and documentation processes.
• Experience in hospice care and case management.

• Hospice coverage required when on-call.
• Must comply with state and federal regulations, and Vermont State Board of Nursing policies.
• Work involves home visits requiring travel and coordination with various healthcare providers.

• Work schedule includes field visits with flexibility to manage caseload and visit times efficiently.
• On-call responsibilities include hospice coverage as required.
• Scheduling coordinated with agency policies to avoid combining supervisory and routine visits.