Job Description SummaryAs part of the innovative Hospital at Home (HAH) team, the HAH registered nurse (HAH RN) is responsible for assessing and triaging possible patients as well as those cared for on the unit, developing and implementing appropriate plans of care, and assuring safe and high-quality care for acutely ill patients in their homes. This RN will be trained for all nursing roles on the HAH team, including in-person screening of patients, assessing and caring for patients virtually, and providing in-home care for patients. Reporting to the HAH Nurse Manager, the HAH RN understands screening of possible patients, and directs patient care, assuring the care plan is fulfilled appropriately knowing when to delegate to other teammates. The HAH RN is excited about this new model of care, is a true team player and participates in process improvement efforts to help grow care provided by the HAH unit.Job DescriptionNursing PracticeAct as the liaison between inpatient/emergency department and HAH Unit for referrals for possible patients.Review patient information to identify possible patients on basic eligibility criteria and plan of care.Conduct eligibility screening of patients, obtain verbal consent and facilitate appropriate transfer to HAH unit.Respond efficiently to HAH patient calls/messages promptly and with compassion.Triage patient concerns and provide appropriate guidance per program/unit policies, procedures and guidelines.Develop individualized patient plan of care, assuring patients’ needs, safety, and personal goals, delegating when appropriate to others on the HAH team. Key teammate in the safe administration of medications as ordered.Provide patient/family education to meet learning styles and appropriate to care provided.Think critically when changes in clinical condition occur, knowing when to appropriately escalate.Collaborate to promote all necessary discharge plans, starting on admission and regularly reevaluated for optimal outcomes.Document all work in the health record per unit and hospital guidelines and policies.Able to perform in-home visits within designated geographic area following all guidelines and policies for care in the home.Education/TeamworkParticipate in all HAH inter-disciplinary rounds, pre-transfer huddles and team meetings, reporting on patient status and movement towards discharge.Assist with creation of patient’s daily schedule to assure all orders will be fulfilled as ordered.Collaborate with all teammates caring for the patient, including paramedics, coordinators, physicians and other in-home partners.Support reinforcement of education regarding the HAH unit with all members of the SSH networkWork closely with leadership on improvement projects, updates and unit growth.Serve in Charge Nurse role as eligible and determined by the Nurse Manager.Safety Awareness – Foster a “Culture of Safety” through personal ownership and commitment to a safe environment.Verify the patient using two unique identifiers.Comply with the current CDC hand hygiene guidelines through proper handwashing, as observed by the nurse manager and peers.Assure appropriate use of personal protective equipment at all times and adheres to universal precautions.Understand and demonstrate individual roles and responsibilities in the event of hospital codes/emergency preparedness.Participate in Collaborative Risk Reviews as requestedProfessional DevelopmentAssume overall responsibility for professional development by incorporating evidenced-based practice, research, and performance improvement initiatives as a part of ongoing practice.Maintain current knowledge/certification licensure and is able to produce evidence of continued education in the field. Pursue professional development to continually develop nursing practice.Practice within the legal boundaries of MA Nurse Practice Act. Direct other licensed and non-licensed personnel as assigned.Display the ability to accept and respond appropriately to feedback and recommendations for change.Demonstrate professional working relationships with colleagues from all disciplines to promote a positive/encouraging workplace.Accountable for being informed about changes in hospital/EMS policy and procedure.Attend all staff meetings, trainings and competencies, with personal accountability for information covered.Technology and Learning Participate in continued learning and possess a willingness and ability to learn and utilize new technology and procedures that continue to develop in their role and throughout the organization. Embrace technological advances that allow us to communicate information effectively and efficiently based on role. Able to navigate multiple technology platforms to support work; to include Epic Care Link, My Chart, MyChart Bedside, Arcadia, TigerConnect, WebEx, and Outlook. Must have a smartphone mobile device available for business use which can support TigerConnect communications at all times during work dayComplianceWork within legal, regulatory and ethical standards relevant to the position.Comply with applicable policies and procedures.Safeguard the privacy and security of patient information. The employee compiles with policies and procedures relating to SSH’s privacy and security programs.Bring potential compliance issues to a manager, supervisor, director or VP.Comply with the mandatory education requirements of the compliance, privacy and security programs.Patient and Family Centered CareConvey respect for values, preferences, and expressed needs of the patient and family.Consider the individual needs of each person with whom they interact, and interacts with sensitivity in the delivery of care/services of diverse populations as needed.Effectively utilize resources to provide care/services- such as interpreter services and on-line sources.Recognize the patient and family according to patient preferences, as important members of the health care team.Collaborate with the patient and family according to patient preferences, in planning, implementing and evaluating care.Welcome the presence and participation of family members at all times according to patient preferences, regardless of other events on the unit/programMinimum Education - PreferredGraduate of an accredited School of Nursing as validated through the Massachusetts Board of Registration in Nursing , Bachelor’s Degree preferredMinimum Work ExperienceMinimum of 2 years experience in acute or emergency settings, working with patients in chronic/complex disease management or home care a plus.Required Licenses/CertificationsRN – Registered Nurse license in the state of MassachusettsBasic Life Support (BLS) CertificationPatient ContactDoes this position have Patient contact YesAge of Patient(s) Adults 18 - 70 years; Geriatrics 70+ yearsRequired additional Knowledge and AbilitiesPrefer highly motivated, team-player, independent-worker, tech-savvy with Epic experience preferred, able to prioritize and organize work based on competing demands and present well- articulated solutions, energetic and experienced nurse (RN). This teammate must be able to adapt to unpredictable circumstance and adopt changes to work quickly and reliably. This individual should have skills in the following areas: customer service, communication, technical platforms and mobile applications, strong interpersonal skills and clinical triage.Chronic Disease Management, Adult age 18 and over, geriatricsGeneral Activity - Frequent Standing/Walking Required, Driving may be requiredMotion - Frequent Activity Required-pushing, pulling, lifting, bendingMotor Skills - Use of hands required, Use of feet requiredWeight/Force Lifting may be required (>25lbs)Body Fluid Exposure - Yes