SUMMARY OF DUTIES AND AREAS OF RESPONSIBILITIES 1. Collaborates with home health interdisciplinary team to review potential wound care patients for Home Care Program and appropriately assesses their eligibility for admission to Home Care. 2. As requested, conducts comprehensive assessment of deep wounds, skin tears, ostomies, severe burns, pressure injuries or bedsores, continence and diabetic foot wounds to determine potential wound complications, immediate treatment needs and long-term treatment plans; works with other members of the health care team to determine if additional treatments or changes in care are required. 3. Utilizes input from patient, caregiver, physician, and peers to devise a wound/ostomy treatment plan which is feasible within the physical, financial and emotional resources of the patient/caregiver to create a care plan for the interdisciplinary health care team including the staff nurses to follow. The assessments consider and record the physical, social, psychosocial, and environmental needs of the patient as it relates to the treatment or evidence-based care that is needed. Collaborates with clinical providers and health care team to establish individualized, comprehensive plan of care for patients with complex wounds, ostomies, and/or continence conditions based on patient risks, diagnosis and individual patient needs. 4. Participates in the development, evaluation and revision of all wound and ostomy management policies for the CHHA based on evidence-based trends and industry standards. Collaborates with direct reports, clinical staff and members of the clinical leadership team in ensuring that evidence-based practices are implemented for wound patients. 5. Provides patient and family education and counseling regarding wound care, risk factors associated with pressure injury, infection prevention, treatment measures and other related issues; provides teaching, guidance and direction to personnel in rendering patient care. Actively involves the patient and caregiver and direct reports in appropriate goal setting for all cases taken under care. 6. Demonstrates a professional attitude and ethical conduct in compliance with departmental standards. Establishes and maintains a cooperative and effective working relationship with the staff, physicians, Case Managers and other hospital personnel, outside vendors, external agencies and the community at large. 7. Writes a clear and concise progress notes that reflect the implementation of the plan of care and the patient’s response to that plan of care. 8. Provides guidance, education and validation of wound and ostomy skills to field nurses (Skilled Nurses). Performs field visits for the purpose of evaluating the skills of field nurses and/or other disciplines. 9. Coordinates appropriate communication and documentation between patients, Home Care Program, medical professionals, and referral sources. Participates in and follows up on all case conferences and interdisciplinary meetings involving wound patients. 10. Collaborates with appropriate staff to establish protocols, which support best practices to achieve optimal clinical outcomes. Serves as a clinical expert to provide field nurses with wound treatment protocols and assists in the education of staff nurses on how to stage wounds. Evaluates nursing documentation and suggest revisions to CLEAR FORM Page 2 of 3 clinical documentation system. Participates in providing in-services/orientation to staff regarding wound/ostomy assessment, care, and documentation. 11. Participates in departmental and interdisciplinary conferences, quality meetings/Quality Committee and/or quality improvement initiatives relating to wound, ostomy and continence issues. Participates collection of all performance improvement data and metrics for wound patients including but not limited financial and clinical metrics and assists with assigned performance improvement data collection. Reviews clinical records to ensure compliance with departmental and regulatory standards. 12. Ensures compliance with state and federal home health regulations as well as NYC H & H Home Care Policies and Procedures. Participates in state or regulatory body surveys as needed. Demonstrates sound judgment by taking appropriate actions regarding suspected violation of corporate compliance regulations. Reports all suspected compliance issues to Chief Nursing Officer, Director of Nursing, Compliance Officer, or Compliance Hotline. 13. Participates in case load reviews and chart audits where appropriate and develops interventions to correct identified deficiencies. Ensures care delivery is rendered using the nursing process, and in accordance with New York State Department of Health and Centers for Medicare and Medicaid Services billing guidelines 14. Performs other duties as assigned including home visits in times of increased demands or scheduling issues
