Essential
? Admission/Assessment/Discharge-
- Ensures patients are eligible for home care services and meet all required program guidelines.
- Exercises independent judgment in day to day responsibilities.
- Completes accurate comprehensive assessments, including OASIS dataset when applicable, to identify physical, psychosocial, developmental, and environmental needs of the patient. Educates the patient, patient representative (if any), and family regarding home care services and assists them in independence with care. Develops and evaluates Home Exercise Programs and teaches patients, patient representative (if any), families and home health aides to implement them.
? Case Management or as an Associated Team Member
- Ensures that the care provided is safe, effective, patient-centered, timely and efficient. This approach achieves optimum value and desirable outcomes for all - the patients, their support systems, the providers and the payers.
- Facilitates the achievement of patient wellness and autonomy through advocacy, assessment, planning, communication, education, resource management and service facilitation.
- Secures and maintains complete physician orders within regulated time frames.
- Provides services that are ordered by the physician as indicated in the plan of care. Develops, evaluates and revises the plan of care based on the initial and ongoing patient assessment, and in partnership with the patient representative (if any) and care givers, meeting all regulatory time frames.
- Communicates and interacts with patients, patient representatives (if any), and families/caregivers in a positive, effective, and professional manner.
- Coordinates the plan of care and participates in ongoing interdisciplinary patient assessment with other nursing staff, physical therapy staff, occupational therapists, speech language pathologists, home health aides, dieticians, and medical social workers, and documents for inclusion in the medical record. Provides effective case management of assigned patients including the utilization of appropriate disciplines, achievement of quality metrics, cost-effective services and the appropriate use of medical supplies.
? Patient and Family Centered Care
Actively engages the patient, patient representative (if any), and family by exhibiting respect and dignity, sharing information in a timely and unbiased manner, and welcoming and encouraging participation to achieve shared decision making.
- Collaborates with other members of the team , including the patient, patient representative (if any), and family, to achieve the ideal patient care experience. ? Delivery of CarePerforms and submits complete and timely documentation of physical therapy assessments, procedures, and interventions in the home according to the plan of care.
- Completes documentation according to established department timelines to ensure inclusion in the medical
record within regulated time frames.
- Ensures that patients meet insurance requirements for home health services.
- Adheres to all Michigan Medicine and department infection control and safety policies.
- Delivers physical therapy according to departmental and professional standards of care.
- Manages assigned patient caseload, and maintains departmental productivity standards.
- Teaches and/or supervises family members and other caregivers in the care of the patient, seeking to
encourage the maximum amount of independence with the care.
- Accountable for utilizing all technology and equipment (i.e., cellular phones, point of care devices,
computers, etc.) according to department expectations and policies.
? Supervisory and General-
- Supervises and assigns Physical Therapy Assistants and Home Health Aides when applicable
- Participates in the Quality Assessment and Performance Improvement (QAPI) program.
- Participates in organization sponsored inservice training.
- Communicates effectively and professionally with colleagues and provides support for smooth functioning
of patient care team.
- Updates required employee information as necessary.
Other Related Duties:
? Practices within the scope of license, certification, or registration.
? Complies with all applicable continuing education requirements .
? Complies with all University of Michigan and departmental standards and expectations.
? Supports the department's commitment to continuous improvement activities and principles through positive and
respectful contribution in all problem-solving and change processes at Home Care Services.
? Performs other duties as assigned.