The self-directed public health nurse provides home care services to Kaiser Permanente patients in community based and facility settings. This position may provide nursing services to patients in the home health, hospice, home infusion, palliative care, or other programs under the direction of the patients physician(s) to provide quality health care outcomes and facilitate the achievement of maximum independence of the patient utilizing health care resources within Kaiser Permanente and the community.

• Provides nursing services to patients consistent with agency policy, state practice acts, and applicable state and federal regulations as directed by the patients physician. Manages the care of patients from admission to discharge, coordinating the multidisciplinary plan of care: including appropriate referrals to other disciplines; community resources; supervision of the home health aid plan of care; coordination of the discharge plan and documentation to reflect all activities provided in program appropriate care settings.
• Assesses the learning needs of the patient/caregiver to develop the plan of care that meets patient and family needs and goals including the provision of effective teaching, supervision and delegation of care to achieve desired health care outcomes and timely discharge consistent with quality care.
• Partners with agency management in the development and review of programs within Continuing Care Services. Facilitates the initiation of cost effective home care and provides consultation to clinicians regarding appropriate care setting alternatives.
• Assures professional competency through maintaining state-of-the-art skills and knowledge consistent with Medicare and JCAHO regulations, applicable nurse practice acts and agency policies.
• Participates in hospice, home infusion, home health and palliative care call duty consistent with agency policy.
• Participates in department quality management/improvement activities; including but not limited to clinical record review, occurrence reporting, focused studies, process and outcome measurement, peer review, continuous quality improvement projects, partners in defining and achieving agency productivity standards.
• Performs other duties as requested.

• One year medical-surgical or ICU nursing experience in an acute care setting, ambulatory nursing (outpatient) or home health, hospice or palliative care, SNF, ALF settings. Two years of experience in Home Health (within the last 5 years) as a LPN may be substituted for the one year of nursing experience.

• Baccalaureate degree in nursing or commensurate knowledge and experience (Commensurate knowledge and experience may include recent experience in areas of care coordination, case management, community health, and public health).

• This job requires credentials from multiple states. Credentials from the primary work state are required at hire. Additional Credentials from the secondary work state(s) are required post hire.
  

• Registered Nurse License (Washington) within 6 months of hire OR Compact License: Registered Nurse within 6 months of hire

• Registered Nurse License (Oregon) within 6 months of hire
  

• Drivers License (in location where applicable)
  

• Basic Life Support
  

• Able to perform complete physical, psychosocial, spiritual assessments.
• Able to operate stethoscope and sphygmomanometer.
• Keyboarding or typing skills.
• Able to learn to operate a laptop computer to perform clinical documentation.
• Working knowledge of concise, yet thorough clinical documentation of patient assessments and care.
• Effective problem solving, written and verbal communication and organizational and time management skills required to accomplish case management responsibilities within allocated time frames.
• Note: This position requires completion of a typing test.
• Note: This position requires a reliable automobile to travel to and from patient homes.

• Operational knowledge of computerized clinical documentation and office application systems including the use of laptop/notebook computers.
• Working knowledge of the managed care industry.
• Knowledge of Medicare regulations/requirements.
• Excellent time management, problem solving and customer service skills.
• Excellent written and verbal communication skills.
• Able to work autonomously and manage patient caseload.
• Knowledgeable of the care for the chronically ill and frail elderly.
• Working knowledge of Hospice and palliative care for the terminally ill patient.
• Pediatrics, including well child care.
• Oncology/hospice.
• Rehabilitation nursing.
• Hospice care and the dying process.
• Peripheral and central line IV management.
• Able to perform venipuncture and IV insertion.
• Able to operate multiple IV pumps.
• Able to perform surgical debridement as part of wound care.

Notes:

• On Call Variable days, holidays and weekends HH RN