To ensure coordination of care & services provided to all patients receiving services in the Home Infusion Program. Key functions are to develop a coordinated admission plan of care for patients referred; facilitate coordination of disciplines & services; use problem-solving & critical thinking skills to facilitate, coordinate, & execute effective, timely responses to clinical problems as they arise for patients; & facilitate transitions across the continuum of healthcare settings for all patients in the Home Infusion Program. The Home Infusion Team Leader, under the direction & in partnership w/the Home Infusion Manager & Home Infusion Supervisor provides clinical leadership for the home infusion team to enhance the delivery of timely high quality & costeffective care which meets all regulatory, accreditation, licensure & certification requirements.
Essential Functions: - Referral & Admissions to Home Infusion: Receives & evaluates appropriateness of the home infusion referral in collaboration w/other team members (care team members, pharmacists, pharmacy technicians, supervisor, scheduler, discharge coordinators, long-term care team, exp&ed care, physicians, clinic social workers, & others as needed). Ensures timely admission based on assessment. Assess clinical implications of services ordered, patient/caregiver ability to manage self-care, requirements for clinical monitoring, vascular access, patient stability, patient behavior that could impact a safe plan of care, & other factors that could impact safety & efficacy of admission care plan. Coordinate appropriate services & interventions by obtaining appropriate initial physician orders (e.g. vascular access, wound care; wound VAC, medications, etc). Participate in the development & coordination of a comprehensive admission plan of care that incorporates an understanding of patient-specific benefits & eligibility requirements in collaboration w/care team, outpatient resources, referring physician & when appropriate, the infusion program medical director. Assure that appropriate supplies & equipment needed to provide initial services are available (e.g. IV supplies, wound supplies, wound VAC, DME, enteral pumps, glucometers, medications, etc) to meet patient needs. - Make recommendations to modify the plan of care to expedite a safe transition of care, reduce risks, & enhance patient outcomes. Conferences w/interdisciplinary home infusion team to identify & communicate start of service to patient/caregiver based on physician orders & patient care needs. Discusses & collaborates w/referral source, home care team members, physician, discharge coordinator, supervisor & in some cases the infusion program medical director regarding complex discharges, unsafe discharge plans, & inappropriate referrals. Assists in identifying & coordinating alternative options to current care needs, which may include on-site or telephone conference w/healthcare team members & patient/family/caregivers. Advocate for the patient & family, as well as the healthcare system to optimize utilization of resources. This includes acting on behalf of the member to ensure they are informed of their financial obligations & understand their appeal rights. Coordinates referrals out to contract & non-contract providers for members that require home care services that can not be provided by agency staff within the Portland/Vancouver service area. Develop & maintain expert level of knowledge & skills related to agency policy, state practice acts, applicable state & federal regulations, utilization management, & qualifications for home care services. - The Home Infusion Team Leader will assist in the supervision of home infusion nursing personnel by: Oversite of day-to-day staffing & patient schedules. Assists w/monitoring of staff performance, provides input into staff evaluations & documentation of performance problems to Home Infusion Supervisor & Home Infusion Manager. Leads daily Am board meeting w/Home Infusion Pharmacy staff. Assists w/interviewing process of applicants & provide hiring recommendations to Home Infusion Supervisor & Home Infusion Manager. Leads case conference/team meetings. - Optimizes the patient's home care plan by providing: Telephone Advice/Problem-solving for patients/caregivers. Follow up to after hours advice calls. Resource, support, & advice for home care staff. Physician communication & support. Facilitates scheduling of follow up visits & procedures related to advice calls. Oversees the day to day staffing & patient schedules & problem-solves staffing challenges to meet patient needs, within staffing rules. Supply & DME ordering. Assistance w/paneling patients w/physicians. Facilitates Care Conferences (Case Conferences, IDT, Complex Discharges, etc). Coordinates care w/Home Phlebotomy. Conducts Medication Reconciliation for Therapy only cases. Reviews & approves Home Health Aide Care Plans for Therapy only cases. - Coordinate, expedite, & track referrals & transitions across care settings (e.g. home phlebotomy referrals, wound program referrals, transfers to inpatient, transfers to ICF/SNF, respites, & across home care programs). Acts as Kaiser Permanente ambassador to provide member information to care facilities (SNF/ICF, assisted living, adult foster care home, & residential care facilities) & problem-solve/facilitate any issues which present barriers to safe transfers & the provision of quality care (e.g. Special equipment needs, symptom/behavior management, financial assessment & plan, clinical instability, & complex care needs. - Provide education & program development functions: Ensures systematic & on-going contact w/hospital staff & other Kaiser Permanente Departments (e.g. LTC, Expanded Care, DME, Hospital Care Coordinators, Clinic Social Workers, Clinic Case Managers, Pharmacy, Home Health & Hospice Program, Membership Services, etc) to share information & ensure safe transitions of care. Provides education to staff to expedite safe transitions of patients across care settings. Participates in orientation of staff to the department. Ensure appropriate & timely care to patients through collaboration w/inpatient staff, CCS home care staff, & outside resource staff. Makes home visits w/Home Infusion Nurses to assure employees providing home infusion care have knowledge & skills required to provide age appropriate care to patients & families through education, training or experience. Provides mentoring & coaching, & input into staff evaluations & documentation of performance problems to Clinical Supervisor. Participates in professional committees & task forces as needed/requested. Ensure regulatory & compliance st&ards are met in collaboration w/others in the inter-disciplinary health care team. Participates in quality & utilization management activities (e.g. Chart audits). Participates in continuing education to incorporate & maintain up to date knowledge & best practices in home infusion & home health. - Provides expert practice consultation for the home infusion team, CCS outpatient & skilled nursing facility staff. Assures professional competency through maintaining state of the art skills & knowledge consistent w/Medicare & JCAHO regulations, applicable nurse practice acts & agency policies. - Conducts patient home visits as required to assist the program in meeting patient needs. Participate in program call duty as needed. Performs other duties as assigned.
Two (2) year of medical-surgical nursing experience in an acute care setting.
Minimum two (2) years of experience within the past five (5) years as a home infusion nurse or home infusion referral nurse.
One (1) year of leadership experience or commensurate experience.
Baccalaureate degree in nursing or commensurate knowledge and experience.
License, Certification, Registration
Current Oregon and Washington RN license required. License in state where assigned required upon hire/transfer, application for license in secondary state required within 2 weeks of hire/transfer and must be obtained within 6 months.
Valid driver's license.
Basic Life Support (BLS) for Health Care Providers required upon hire/transfer.
Demonstrated ability to collaborate with physicians, ancillary providers, nurses, and patients to plan for transition of care to and from the home setting.
Able to perform complete physical, psychosocial, spiritual assessments.
Able to operate stethoscope and sphygmomanometer.
Keyboarding or typing skills.
Able to operate a computer to perform clinical documentation.
Highly effective problem-solving, written and verbal communication, organizational, and time management skills.
Knowledge of Medicare, The Joint Commission, and State requirements and regulations for home care programs.
Knowledge of Kaiser Permanente systems.
Note: This position requires completion of a typing test.
Note: This position requires a reliable automobile to travel to and from patient homes.
Four (4) years of experience as a registered nurse in the acute care preferably medical/surgical and/or critical care nursing and at least one your working in a Kaiser Permanente Home Care Program (Home Infusion, Home Health, Hospice, or Palliative Care).
Experience with care coordination or case management.
Home health nursing.
Pediatric and well child nursing.
Oncology and hospice nursing.
IV therapy nursing.
Rehabilitation nursing. Pediatrics, including well child care.
Hospice care and the dying process.
Utilization management, discharge planning, care coordination, and case management. Demonstrated customer-focused service skills.
Familiarity with the use of computers and competence in keyboarding skills.