Marketing Statement NYC Health + Hospitals/At Home reaches outside the walls of our hospitals and brings health care to patients where they live. With more than 600 dedicated employees, Community Care provides services including home care, community care coordination, and community-based care management to individuals managing chronic health conditions residing in Brooklyn, Manhattan, Queens and The Bronx. Job Description 1. Provides services requiring specialized nursing skill in management of behavioral health disorders, in accordance with the plan of treatment signed by the treating psychiatrist and makes the initial evaluation visit to adult clients with chronic behavioral health disorders.2. Demonstrates competency in all skills required for the agency, including, but not limited to assessment of behavioral health needs, medication teaching, patient teaching and anticipation of needs in relation to realistic goals for optimal functioning. 3. Prior to initial visit, assembles pertinent information regarding history of behavioral health disorder, history of medication compliance, history of violence and any other pertinent information from medical record to help guide initial interactions with behavioral health clients.4. Evaluates, and regularly reevaluates behavioral health needs as well as co-morbid medical nursing needs of the client; initiates, develops, implements and makes necessary revisions to the client’s plan of care. Completes comprehensive patient assessment on all patients including OASIS as indicated. Assesses the client’s continual care needs. Addresses all problems in the plan of care or documents rationale for not doing so.5. Communicates with the Director of Nursing for Behavioral Health Management as needed for questions/issues related to best practices of behavioral health disorders, creation of appropriate and realistic client-centered goals and safe practices in home care as related to such.6. Closely monitors compliance with prescribed psychiatric medications.7. Reports to the psychiatrist, multidisciplinary team any evidence of non-compliance with psychiatric medications within 24 hours. In cases of concern that client is a potential harm to self or others reports psychiatric mediation non-compliance or concerning behavior/symptoms immediately to psychiatrist and seeks direction from the Director of Nursing Behavioral for Behavioral Health Management involving emergent situations of concern.8. Initiates diagnostic, preventive and rehabilitative behavioral health nursing procedures as appropriate to the client’s care and safety. Makes referrals to other disciplines in collaboration with the psychiatrist, client and family as indicated by the client’s needs or documents rationale for not doing so.9. Observes signs and symptoms and reports to the psychiatrist and/or other appropriate health professionals as often as needed, or upon changes in the client’s condition/symptoms.10. Teaches, supervises and counsels the client and family regarding behavioral health best practice procedures and other care needs as appropriate to the client’s condition. Utilizes agency educational material as appropriate.11. Coordinates the total plan of care and maintains continuity of client care by liaising with other health professionals assigned to the same clients. Attends client care conferences. Initiates client care conferences for complex and/or multidisciplinary clients whenever needed.12. Supervises and teaches the home health aide for any co-morbid medical conditions. Every two weeks, assesses the client’s need for unskilled care and revises the plan of care as appropriate. Communicates the plan of care changes to the aide and scheduler as often as necessary.13. Develops, prepares and maintains individualized client care progress records with accuracy, timeliness and according to policies. Submits accurate documentation within 48-72 hours of visit. Completes 60-day summaries, discharge summaries, OASIS start of care, follow up and resumption of care forms, OASIS transfer, death at home forms as indicated.14. Responsible for following all policies and procedures of the agency regarding service delivery, documentation and care coordination. During supervisory visits, exhibits full compliance and verbalizes knowledge of agency policies including but not limited to client education, behavioral health management, infection control and management of hazardous wastes and age-specific behaviors for clients.15. Participates in the agency’s quality improvement program.16. Participates in biweekly clinical record reviews as requested.17. Maintains current personnel file information and provides information to agency in timely manner.18. Sets own development challenges and volunteers to learn.19. Assists with orientation of new personnel.20. Attends agency provided in-service programs (e.g.-BLS) to fulfill requirements of position and agency policies.
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